Transcript Slide 1
February 2014 Jean C. Russell, MS, RHIT [email protected] Richard Cooley, BA, CCS [email protected] Matthew H. Lawney, MSPT, MBA, CHC [email protected] 518-430-1144 2 Agenda Payment Basics Challenges in Radiology Diagnostic Radiology Radiation Oncology Echo with Contrast 3 Payment Basics 4 Outpatient Reimbursement Medicare Non-OPPS Mammography- Status A Paid on a Fee Schedule Not subject to deductible or coinsurance OPPS Technical/ facility- paid under Medicare APCs Professional component and are “split billed” 5 Medicare Status S, T, X Paid under APCs T Significant Procedure, Not Discounted When Multiple Significant Procedure, Multiple Reduction Applies X Ancillary Services S 6 Medicare Status Q Q1 STVX-Packaged Codes Q2 T-Packaged Codes Q3 Codes That May Be Paid Through a Composite APC 7 Revenue Codes Revenue codes– 32x– Diagnostic Radiology 333– Radiation Therapy 34x– Nuclear Medicine 35x– CT 40x – Mammo, US, and PET 61x– MRI/ MRA 7 8 Medicaid Medicaid APGs OP Visits Radiology studies are billed under the appropriate rate code; e.g., clinic (1432), ED (1402) Referred ambulatory tests will bill separately- no rate code 8 “Referred Amb” (Ambulatory (walk-in) referred by outside physician) – covered under Medicaid ambulatory fee schedule 9 APG Payment Hierarchy Significant Procedures: A procedure/service which constitutes the reason for the visit and dominates the time and resources expended during the visit Payment based on HCPCS code Medical Visits: A visit during which a patient receives medical treatment but does not have a significant procedure performed Payment based on the primary diagnosis Ancillary Tests and Procedures: A test or procedure to assist in patient diagnosis or treatment Ancillary service APG assigned in the absence of Significant Procedure or Medical Visit Payment (if paid) based on HCPCS code 9 9 10 Ancillary Billing Policy Payment for laboratory and radiology services ordered by practitioners in hospital‐based outpatient clinics is made to the clinic The ancillary service provider may not bill Medicaid directly for lab or the technical component of radiology services related to an APG‐reimbursed visit Therefore must bill the ordering clinic for the service provided to clinic patients 10 10 11 Challenges in Radiology 12 Radiology Coding Challenges Radiology charge capture poses unique challenges due to the high volume of procedures performed in hospital outpatient radiology departments and the multiple departments involved in charge capture and coding Outpatient diagnostic radiology procedures can cause coding concerns as they can include hardcoded (CDM) and soft-coding (HIM) Interventional Radiology Procedures 13 Radiology Coding Challenges Increasing number of Radiology procedures are being packaged into surgical codes: Challenging to track radiology revenue Productivity issues Pricing issues Reimbursement modeling challenges Cost Center Impact Outpatient Revenue by Rev Code (based on charges) Percent of Dept Sum Charges Revenue codes charges Radiology $865,387,583.31 32x,33x,34x,35x,40x,61x 27% Laboratory $597,534,308.22 30x,31x,39x 18% Surg/treat $563,974,920.56 36x,49x,75x,76x 17% Pharmacy $275,423,132.66 25x,63x 9% Clinic $187,565,145.47 51x 6% Supplies $184,253,430.67 27x,62x 6% Cardiology $163,574,163.94 48x 5% ED $158,385,228.70 45x 5% PT, OT, SP, Audio $86,601,517.95 42x,43,44x,47x 3% Psych $68,700,757.68 90x,91x 2% EEG, EKG $48,542,058.96 73x,74x 2% Pulm, resp $20,601,454.81 41x,46x 1% IV Therapy $12,403,930.75 26x 0% Oncology $1,047,887.23 28x 0% Miscellaneous $226,542,222.03 7% 14 15 Cost Center Chart Percent of charges Radiology Laboratory Surg/treat Pharmacy Clinic Supplies Cardiology ED PT, OT, SP, Audio Psych EEG, EKG Pulm, resp IV Therapy Oncology Miscellaneous 15 16 Charging Concerns Modifiers have significant impact Payments are complicated by increased packaging and bundling NCCI edits Many surgical procedures include the radiology procedure in the surgical code and therefore the radiology component is not separately reported 18 Description Change Cervical Spine Codes 72040 Radiologic examination, spine, cervical; 2 or 3 views (was 3 views or less) Code 72040 was revised to define the exact number of views to be reported. For a single view radiologic examination of the cervical spine, use 72020, Radiologic examination, spine, single view, specify level. 19 Deleted Codes None 20 21 New Code There is one new add-on code: 77293 - Respiratory motion management simulation (List separately in addition to code for primary procedure) Used in conjunction with 77295, 77301 77295 – 3-dimensional radiotherapy plan, including dosevolume histograms 77301 – Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications 22 Revised Code 77295 - 3-dimensional radiotherapy plan, including dose-volume histograms 2013 Description: 77295 - Therapeutic radiology simulation 3 - dimensional radiotherapy plan, including dose- aided field setting volume histograms; 3-dimensional 24 Category III codes Used to report new technology They are carrier priced if the service is covered Updates are posted biannually (January and July) and are effective six months after posting This delay provides time for providers/payers to update systems These codes are maintained until they meet Category I code requirements or they are archived after five years unless a further need is demonstrated to maintain the Category III code status 25 New Codes Myocardial sympathetic innervation imaging codes 0331T and 0332T were available for use on July 1, 2013 and are now listed in the CPT 2014 codebook. 0331T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment 0332T Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT (For myocardial infarct avid imaging, see 78466, 78468, 78469) 26 New Codes The following Category III codes were released July 2013 and may be used as of January 1, 2014: 0338T - Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral 0339T - bilateral (Do not report 0338T, 0339T in conjunction with 36251, 36252, 36253, 36254) 27 New Codes The following Category III codes were released July 2013 and may be used as of January 1, 2014: 0340T - Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance (Do not report code 0340T in conjunction with 76940, 77013, 77022) 0346T - Ultrasound, elastography (List separately in addition to code for primary procedure) (Use 0346T in conjunction with 76536, 76604, 76645, 76700, 76705, 76770, 76775, 76830, 76856, 76857, 76870, 76872, 76881, 76882) (For elastography without other imaging procedures, use unlisted code) 28 Extended Codes Cerebral Perfusion Analysis 0042T - Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 29 Deleted Codes 0078T, 0079T, 0080T, and 0081T have been deleted for 2014. To report see 34841-34848 Covered in IR Session 30 Questions and Discussion 31 Contact Us Richard Cooley Phone: Email: 518-430-1144 [email protected] Jean Russell Phone: Email: 518-369-4986 [email protected] Matt Lawney Phone: Email: 845-642-6462 [email protected] 32 http://www.EpochHealth.com/ 33 CPT® Current Procedural Terminology (CPT®) Copyright 2012 American Medical Association All Rights Reserved Registered trademark of the AMA 34 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.