Equip Your Radiology Practice with Audit Essentials
Four best practices when following radiology compliance regulations.
By Kim Wells, CPC, CPMA, CEMC, AAPC Fellow
The issue of healthcare fraud and abuse has attracted a lot of attention in recent years, primarily because the financial losses attributed to it are estimated to be billions of dollars, annually. Below are four tips for ensuring your practice and the radiology services your clinicians provide are audit-strong.
No. 1: Use Guidelines and Resources
Know what guidelines to follow and what valuable resources are available to ensure you are accurately reporting your services. For example, review new, deleted, and revised CPT® codes, at least yearly, and ensure all providers and staff are educated on changes. Sources that will provide you with additional information on CPT® updates include, CPT® Changes: An Insider’s View, CPT® Assistant, and Clinical Examples in Radiology. Other valuable coding references include:
- The Center for Medicare & Medicaid Services (CMS):
- Medicare Claims Processing Manual, Publication 100-04, Chapter 13: Radiology Services and Other Diagnostic Procedures
- Medicare Benefit Policy Manual, Publication 100-02, Chapter 15: Section 80.6 – Requirements for Ordering and Following Orders for Diagnostic Tests
- Medicare National Coverage Determinations (NCDs)
- Medicare administrative contractors’ Local Coverage Determinations (LCDs)
- Office of Inspector General annual work plan
- On the American College of Radiology(ACR) website
(www.acr.org), you can look up information about:
- Quality and safety
- Clarification on ordering of diagnostic tests rule
- Supervision rules
- ICD-10-CM coding guidelines
- Coding topics
There are also sources that will help you with ICD-10-CM guidelines and yearly updates. For example, ICD-10-CM Official Guidelines for Coding and Reporting and the Medicare Claims Processing Manual – Chapter 13, which has several examples of diagnosis coding scenarios.
AAPC Coder (www.aapc.com/code/) is an excellent and quick resource for coding guidance and guidelines of CPT®, ICD-10, HCPCS Level II, modifiers, CPT® Assistant, AAPC Code Assist, AHA Coding Clinic, and AAPC Coder Survival Guides.
No. 2: Make Sure Documentation
Shows Medical Necessity
Medical necessity is essential for every service provided. All services must be sufficiently documented in such a way that medical necessity of all rendered services and supplies is evident. Medicare cannot pay for services for which the documentation does not establish medical necessity. Section 1862(a)(1)(A) of Title XVIII of the Social Security Act provides, “No payment may be made under Part A or B (of Medicare) for any expense incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Radiology providers can do something about claims that Medicare and other payers deny for lack of medical necessity: Take steps to implement management processes to reduce denials. This requires extra effort and cooperation of referring providers, radiologists, and staff. Be sure to understand the definitions of medical necessity with which you must comply.
Although the definitions may differ, most payers incorporate the terms “reasonable” and “necessary” when considering clinical practice standards. You may find the definitions on your payer’s website, and if not, request this in addition to their clinical review criteria.
Become knowledgeable about Medicare’s NCDs and LCDs for radiology services. Both sets of guidelines, as well as the guidelines you probably won’t get from non-Medicare payers, are very important to submitting claims that are supported with documented medical necessity.
No. 3: Know Why the Tests Are Being Referred
Radiology documentation of clinical information from the referring/requesting provider is vital to have when the patient is registered for diagnostic services.
A clarification from the ICD-10-CM guidelines states that, when the interpreting physician does not have diagnostic information on the reason for the test, and the referring physician is unavailable to provide that information, it is appropriate to obtain the information directly from the patient or the patient’s medical record. The CMS Program Memorandum Intermediaries/Carriers Program Memorandum Services, Transmittal AB-01-144 (ICD-9-CM Coding for Diagnostic Tests), however, says that “an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.” The program memorandum does not specify who in the interpreting physician’s office must obtain this information.
No. 4: Check Up On Physician Documentation
Beyond proving medical necessity, physician documentation is a key element to compliance. The report documentation is what tells the story of the patient’s diagnostic procedure from A to Z, and it must match the billing document when an audit is conducted. Remember the coder’s mantra: “If it’s not documented, it didn’t happen.”
Although the term “audit” can bring thoughts of uncertainty and concern, being proactive in all facets of radiology compliance regulations, clinically and in coding and billing, will help you feel secure in knowing you have followed best practices. The ACR provides a step-by-step diagnostic imaging report and signature guidelines that can help you better understand compliance so that your office passes compliance audits with confidence.
ICD-10-CM Official Guidelines for Coding and Reporting www.cms.gov/Medicare/Coding/ICD10/Downloads/2017-ICD-10-CM-Guidelines.pdf
Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdf
Medicare Benefit Policy Manual, Chapter 15: Section 80.6 – Requirements for Ordering and Following Orders for Diagnostic Tests: www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.PDF
Section 1862(a)(1)(A) of Title XVIII of the Social Security Act: www.ssa.gov/OP_Home/ssact/title18/1862.htm
CMS, Program Memorandum Intermediaries/Carriers, ICD-9-CM Coding for Diagnostic Tests, Change Request 1724: www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/ab01144.pdf
Kim Wells, CPC, CPMA, CEMC, AAPC Fellow, is a physician compliance auditor with Baylor Scott and White Health in Texas. With over 30 years’ experience, she has assisted many physician practices in meeting federal and state regulatory guidelines. Wells has spoken at coding and practice management conferences for physician society meetings, local colleges, local and national AAPC events. She is a member of the Scottsdale, Ariz., local chapter, but will be relocating to Texas soon and will become a local chapter member there.