February 2014

Jean C. Russell, MS, RHIT jrussell@epochhealth.com

Richard Cooley, BA, CCS rcooley@epochhealth.com

Matthew H. Lawney, MSPT, MBA, CHC mlawney@epochhealth.com

518-430-1144

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AgendaPayment BasicsChallenges in RadiologyDiagnostic RadiologyRadiation OncologyEcho with Contrast

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Outpatient ReimbursementMedicareNon-OPPS

Mammography- Status APaid on a Fee ScheduleNot subject to deductible or coinsurance

OPPSTechnical/ facility- paid under Medicare APCsProfessional component and are “split billed”

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Medicare Status S, T, X

SSignificant Procedure, Not Discounted When Multiple

TSignificant Procedure, Multiple Reduction Applies

X Ancillary Services

Paid under APCs

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Medicare Status Q

Q1 STVX-Packaged Codes

Q2 T-Packaged Codes

Q3 Codes That May Be Paid Through a Composite APC

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Revenue CodesRevenue codes–

32x– Diagnostic Radiology333– Radiation Therapy 34x– Nuclear Medicine35x– CT40x – Mammo, US, and PET61x– MRI/ MRA

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MedicaidMedicaid APGs

OP VisitsRadiology studies are billed under the appropriate rate

code; e.g., clinic (1432), ED (1402)Referred ambulatory tests will bill separately- no rate

code “Referred Amb” (Ambulatory (walk-in) referred by outside

physician) – covered under Medicaid ambulatory fee schedule

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APG Payment HierarchySignificant 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

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Ancillary Billing PolicyPayment 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

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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 hard-coded (CDM) and soft-coding (HIM)Interventional Radiology Procedures

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Radiology Coding Challenges

Increasing number of Radiology procedures are being packaged into surgical codes:Challenging to track radiology revenueProductivity issuesPricing issuesReimbursement modeling challenges

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Cost Center ImpactOutpatient Revenue by Rev Code(based on charges)

Dept Sum Charges Revenue codesPercent of 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%

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Cost Center ChartPercent of charges Radiology

Laboratory

Surg/treat

Pharmacy

Clinic

Supplies

Cardiology

ED

PT, OT, SP, Audio

Psych

EEG, EKG

Pulm, resp

IV Therapy

Oncology

Miscellaneous

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Charging ConcernsModifiers have significant impactPayments are complicated by increased

packaging and bundlingNCCI edits

Many surgical procedures include the radiology procedure in the surgical code and therefore the radiology component is not separately reported

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Description ChangeCervical 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.

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Deleted CodesNone

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New CodeThere 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 dose-

volume histograms 77301 – Intensity modulated radiotherapy plan, including

dose-volume histograms for target and critical structure partial tolerance specifications

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Revised Code77295 - 3-dimensional radiotherapy plan, including

dose-volume histograms2013 Description:

77295 - Therapeutic radiology simulation 3 -dimensional radiotherapy plan, including dose- aided field setting volume histograms; 3-dimensional

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Category III codesUsed to report new technology

They are carrier priced if the service is coveredUpdates 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

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New CodesMyocardial 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 assessment0332T Myocardial sympathetic innervation imaging,

planar qualitative and quantitative assessment; with tomographic SPECT (For myocardial infarct avid imaging, see 78466, 78468, 78469)

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New CodesThe 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)

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New CodesThe 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)

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Extended CodesCerebral 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

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DeletedCodes 0078T, 0079T, 0080T, and 0081T have been

deleted for 2014. To report see 34841-34848Covered in IR Session

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Contact UsRichard Cooley

Phone: 518-430-1144

Email: RCooley@EpochHealth.Com

Jean RussellPhone: 518-369-4986

Email: JRussell@EpochHealth.Com

Matt LawneyPhone: 845-642-6462

Email: mlawney@EpochHealth.Com

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http://www.EpochHealth.com/

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CPT®

Current Procedural Terminology (CPT®) Copyright 2012 American Medical AssociationAll Rights ReservedRegistered trademark of the AMA

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DisclaimerInformation 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.