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Kim Wells CPC, CPMA, CEMC

Understanding the New Radiology Codes for 2017

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Know Your Codes

Healthcare fraud and abuse are hot topics right now, healthcare organizations are practically bleeding revenue. It’s more important than ever to get on top of new codes and keep your practice audit-ready. Use this guide to update CPT codes and accurately report your services.

Billions Lost Annually to Healthcare Fraud

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.

Healthcare fraud: An intentional attempt to wrongfully collect money relating to medical services.

Healthcare abuse: actions which are inconsistent with acceptable business and medical practices

The federal False Claims Act (FCA) imposes

civil liability on persons who knowingly submit a false or fraudulent claim or engage in various types of misconduct involving federal government money or property.

HEALTHCARE PROGRAM FALSE CLAIMS OFTEN ARISE IN BILLING FOR:

• Services not rendered

• Unnecessary medical services

• Double billing for the same service or equipment

• Services at a higher rate than provided (“upcoding”)

• Incorrect codes

• National Correct Coding Initiative edits (NCCI) and Medically Unlikely edits (MUEs)

• Insufficient documentation

Keep Your Practice Audit-Ready

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Accurately Report Your Services with These New Codes

Get on top of the new radiology codes to keep your practice forever audit ready. Know what Guidelines to follow and what valuable resources are available to ensure you are accurately reporting your services. On a yearly basis, make sure you review new, deleted, and/or revised CPT codes and that all providers and staff are educated.

SOME OF THE 2017 NEW DIAGNOSTIC CODES ARE:

• 77065 - Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral

• 77066 - Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral

• 77067 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed – per ACR when performed unilateral use modifier -52, reduced service or carrier specific (-52, RT/LT).

CMS HAS ELECTED NOT TO USE THE NEW CPT 2017 CODES THAT BUNDLE CAD (COMPUTER-AIDED DETECTION) WITH MAMMOGRAPHY SERVICES INSTEAD CONTINUE TO USE:

• G0202 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (cad) when performed

• G0204 - Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral

• G0206 - Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral

• Also new is: 76706 replaces G0389 to describe ultrasound screening for AAA (abdominal aortic aneurysm.)

• For a complete list of the new 2017 Radiology codes please refer to the American College of Radiology’s (acr.org) article along with the 2017 CPT booklet.

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Resources to Help You Stay Current

Knowledge is power and resource lists always come in handy. Stay current by educating providers and staff using the following auditing and compliance resources.

SOURCES THAT WILL PROVIDE ADDITIONAL INFORMATION TO CPT CODES ARE:

• CPT Changes: An Insider’s View

• CPT Assistant

• Clinical Examples in Radiology

CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS):

• Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures

• Medicare Benefit Policy Manual, Chapter 15: Section 80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests

• Medicare National Coverage Determinations (NCD)

• Local Medicare Administrative Contractors (MACs) Coverage

Determinations (LCD)

• Review the Office of Inspector General (OIG) yearly work plan

AMERICAN COLLEGE OF RADIOLOGY (ACR.ORG)

• Quality and Safety

• Clarification on Ordering of Diagnostic Tests Rule

• Supervision Rule

• ICD 10 CM Coding Guidelines

• Coding Topics

ICD 10 CM GUIDELINES AND YEARLY UPDATES

• Example: Conventions for the ICD-10-CM: 19. Code assignment and Clinical Criteria. The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

• The Medicare Claims Processing Manual, Chapter 13, has several examples of

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diagnosis coding scenarios.

• AAPC Coder Software Application is an excellent and quick resource for CPT/ICD-10/HCPCS/Modifiers/CPT Assistant/Code Assist/AHA Coding Clinic and AAPC Coder Survival Guides.

Medical Necessity is essentially important for every service that you provide to your patients. The following is an excerpt from the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.1 and is followed by all auditors:

“Medical necessity of a service is the

overarching criterion for payment in addition

to the individual requirements of a CPT code.

It would not be medically necessary or

appropriate to bill a higher level of evaluation

and management service when a lower

level of service is warranted. The volume of

documentation should not be the primary

influence upon which a specific level of service

is billed. Documentation should support the

level of service reported.” Furthermore, all

services must be sufficiently documented

so the medical necessity is clearly evident.

Medicare cannot pay for services for which the

documentation does not establish the 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.”

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Diagnostic Test Ordering

Radiology documentation of clinical information from the referring/requesting provider is the most important procedure to implement upon patient registration for diagnostic services.

A clarification from the ICD-CM guidelines state that, when the interpreting physician does not have diagnostic information on the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record.

However, the CMS Program Memorandum states “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.

Clinical Report Documentation

In addition to medical necessity compliance for the service performed, physician documentation is a key element.

The ACR provides a Step-by-Step Diagnostic

Imaging report and signature guidelines that will ensure accuracy and compliance with the knowledge and assurance you will pass your audits with confidence.

The documentation is what tells the story of the patient’s diagnostic procedure from A to Z and must match the billing document when an audit is conducted. Remember the famous phrase “If it’s not documented it didn’t happen.”

Survive a Government Audit Using Best Practices

While 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 to survive a potential government or private carrier audit.

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Kim Wells CPC, CPMA, CEMC Kim started her career processing insurance claims in 1983 and advanced quickly into Practice Management with multi-specialty groups such as Radiology, Cardiology, Family Practice, Internal Medicine, Endocrinology, Infectious Disease, Neurology, Urology, General Surgery, OB-GYN, Orthopedic Spine, Physiatry, Pediatric Hospitalists, Digestive Disease, Urgent Care and Free Standing Emergency Department. Her coding and billing knowledge along with her leadership skills assisted many physician practices towards meeting federal and state regulatory guidelines. Through proactive leadership in local AAPC, MGMA, AAHAM chapters she held many membership chairs and has been requested to speak at coding and practice management conferences for Physician Society meetings, local Colleges and the National AAPC. She became an entrepreneur providing physician coding, practice management, billing and consulting services and educating providers on coding guidelines, human resource, and best practice physician office standards. She continues to assist physician groups today with E/M and Specialty coding audits displaying her vast knowledge while staying current in the ever changing healthcare field.

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