John Marshall CRA, RCC, RT(R), FAHRA [email protected]How to Get Paid for Imaging Services Performed in Surgery Disclaimer Disclaimer John Marshall, his wife Adrienne and their dog Shakespeare, specifically disclaim liability or responsibility for the results or consequences of any actions taken in reliance on anything in this presentation or the accompanying materials. We also apologize for any and all embarrassing remarks that come out of John’s mouth during this presentation. The information provided in this presentation is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, policies, and payment amounts. All content in this presentation is informational only, general in nature and does not cover all situations or all payers’ rules and policies. This content is not intended to instruct hospitals and/or physicians on how to use or bill for healthcare procedures including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that is assumed to have been made prior to assigning codes or requesting payments. Hospitals and physicians should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing and payment levels for healthcare procedures. This presentation represents no promise or guarantee concerning levels of reimbursement, payment, coding, billing and coverage issues. • Getting Paid • Regulations and Obstacles • Turf Battles and Politics • Fluoroscopy and RS&I • Real-Life Examples • Solutions and Options Today Today’ s Agenda: s Agenda:
DisclaimerDisclaimerJohn Marshall, his wife Adrienne and their dog Shakespeare, specifically disclaim liability or responsibility for the results or consequences of any actions taken in reliance on anything in this presentation or the accompanying materials. We also apologize for any and all embarrassing remarks that come out of John’s mouth during this presentation.
The information provided in this presentation is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, policies, and payment amounts. All content in this presentation is informational only, general in nature and does not cover all situations or all payers’ rules and policies. This content is not intended to instruct hospitals and/or physicians on how to use or bill for healthcare procedures including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that is assumed to have been made prior to assigning codes or requesting payments. Hospitals and physicians should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing and payment levels for healthcare procedures. This presentation represents no promise or guarantee concerning levels of reimbursement, payment, coding, billing and coverage issues.
2008 HOPPS Packaging Policies2008 HOPPS Packaging Policies• Image Processing• Radiopharmaceuticals and Contrast Media
• Supervision & Interpretation Services
• Guidance
• Intra-Operative Services
Packaged Interoperative ServicesPackaged Interoperative ServicesServices provided in support of other dependent minor procedures or diagnostic testing.
Intravascular US Follow-Up Angiography
Operative Hip Thyroid Met Uptake
Operative Cholangiogram Wall Motion Add-On
Ejection Fraction Add-On First Pass Add-On
Bundling Versus PackagingBundling Versus Packaging
Bundling
Packaging
Coding Term
Applied to Sub-Components
Not Reported Separately
Financial Term
Reimbursed Elsewhere
Reported Separately
“We encourage hospitals to report all charges for all services on claims for data on which the relative weights are set. This will insure the accurate reporting of the relative costs for all services.”
Fed Reg, Volume 68 #216
Nov. 7, 2003, Pg 63425
Packaged Services MUST Be Reported!
Yes, the Hospital still gets reimbursed.Yes, the Hospital still gets reimbursed.
Gall Bladder– 2007 $4,499 + $107 Cholangiogram– 2009 $6,366 Includes all charges
Hip Pinning– 2007 $10,625 + Fluoroscopy + $76 OR Hip– 2009 $11,346 Includes all charges
Billing Issues• Surgical Component• RS&I Component• NCCI Edits• Bundling• Packaging• Operating Statistic = Minutes and Levels (soft codes)• Imaging Statistic = Units of Service (cpt)• Professional Fee: Radiologist versus Surgeon
ACR Guidance on Fluoroscopy ACR Guidance on Fluoroscopy
Fluoroscopy is considered a part of such procedures as…– gastrointestinal exams - arthrography – myelography - cholecystography– venography - angiography – arteriography - cystography
……and is not coded separately.and is not coded separately.
AMA Guidance
CPT Assistant, February 2007
Radiologic supervision and interpretation codes for specificprocedures include all the radiologic services necessary for that procedure.
For example, do not additionally report fluoroscopy (e.g., CPT codes 76000, 76001, 77002, 77003) or ultrasound guidance (e.g., CPT codes 76942, 76998)."
National Correct Coding InitiativeNCCI Manual, Chapter 9
"Unless specifically noted, fluoroscopy necessary to complete a procedure and obtain the necessary permanent radiographic record is included in the major procedure and should not be reported separately."
FluoroscopyFluoroscopy76000 Fluoroscopy (separate procedure), up to one hour physician time
• Designated as a separate procedure – Status ‘T’
• Inherent in all RS&I codes
• Reported when fluoroscopy is the only imaging performed and no radiographs produced
FluoroscopyFluoroscopy76001, Fluoroscopy, physician time more than one hour,
assisting a non-radiologic physician
• May Be Billed With Other Procedures
• Status ‘N’ Not Paid Separately By Medicare
• Inherent in all RS&I codes
• May be reported for >53 minutes of dedicated staff and equipment availability
• Reported when fluoroscopy is the only imaging performed and no radiographs produced
• Over 53 Minutes = One Hour (Rule 882)
• Dedicated Technologist and Equipment
• NOT Fluoroscopy Time
76001, Fluoroscopy, physician time more than one hour,assisting a non-radiologic physician
All CPT codes are not restricted to a specific specialty group. Any CPT code may be used to designate the procedures or services rendered by a qualified physician or other qualified healthcare professional
76001, Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician
2010 cpt Professional Edition, Introduction
77001, Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)
Central Venous Access Central Venous Access -- FluoroscopyFluoroscopy
Statistical ‘Charge’: Post CVC Placement CXR
Localization and Needle Placement77002 Fluoroscopic guidance for needle placement (eg, biopsy,
aspiration, injection, localization device)
• Only Non-Spinal Needle Placement Performed
• Do Not Report With an RS&I Code
• More Likely to Occur in Pre-OP or Recovery
Pain Injections77003 Fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction
• Predominately Pain Management
• Do not report with RS&I
• Do not report with Facet Injections (64490-64495)
Pacemakers
71090 Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation
• Reported for both pacemakers and defibrillators
• Report post-implant Chest radiograph separately
Surgery Reports Surgical Components
Radiology Reports RS&I or Statistic
A/V DialysisDescription of Procedure:
… Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis. Fistulagram was performed showing…
Original Charge Reported: 76000 < One Hour Fluoroscopy
IN FLOW
Brachial Artery
OUT FLOW
Basilic or Cephalic Vein
DIALYSISGRAFT
Arterial Anastomosis
VenousAnastomosis
A/V Dialysis
Statistic Charge needed for AV Fistulagram as Only Procedure
76000 Fluoro <1 Hour $0 N/A Statistical Charge $036147 AV Fistulagram $157 36147 AV Fistulagram $157
$157 $157
Original Charges Corrected Charges
APC Reimbursement:Units of Service:
$0+1
A/V DialysisDescription of Procedure:
… Local anesthesia was applied in the graft apex and a small skin incision was made. Graft was accessed medially towards the venous anastomosis. Fistulagram was performed showing clot and stenosis of radial artery beyond the anastomosis.
…was angioplastied with a 7 mm x 4 cm balloon, and there was immediate recoil with a persistent 80% stenosis. This was then stented with a 10 mm x 25 mm Express stent with no residual stenosis.
Following preparation and draping of the skin and under fluoroscopic control, 20 gauge needles were inserted into the disc spaces at the L2-3, L3-4 and L4-5 levels. Contrast was injected and the level of pain was determined.
Original Charge Reported: 76001 Fluoro One Hour
Spine Fluoroscopy
Discograms are coded per each vertebral disc injected
Following successful induction of general anesthesia, The left cervical region was prepped and draped in a sterile fashion. Fluoroscopy was used to identify the appropriate level. The spinous processes of C-3 and C-4 were resected….
Original Charge Reported: 76000 Fluoro Less Than One Hour
The patient brought to the operating room … The ventricular lead was passed first. The battery pack then as mentioned was a St. Jude model #PM2210, was implanted in the pocket and the pocket was closed in three separate layers.
Original Charge Reported: 76000 Fluoro <1 Hour and 71090 Pacer Fluoroscopy
Pacemaker
Check the Surgery Department’s Standard Charges or Preference Card
APC Reimbursement: $0Units of Service: OR -1 Rad +1
Original Charges Corrected Charges
Central Venous AccessDESCRIPTION OF PROCEDURE:
… Venous aspirate was without resistance and the wire was passed without resistance. The fluoroscopy was used to confirm adequate positioning of the wire into the vena cava. … The catheter was cut to the appropriate length and secured to the port. The port was aspirated and flushed with no resistance to flow. The final position was confirmed with fluoroscopy.
Original Charge Reported: 77001 CVC Fluoro and 71010 Chest Single View
Central Venous Access
CVC Fluoroscopy includes post radiograph - Statistical Charge Suggested
76000 Fluoro <1 Hour $0 77001 Insert Venous Catheter $071010 Chest Single View $44 none Chest Post CVC Fluoro statistic
$44 $0
Original Charges Corrected Charges
APC Reimbursement Change: ($44)Units of Service: OR -1 Rad +1
Breast SpecimenPROCEDURE IN DETAIL:
…incision …we then were able to identify the wire and the wire was then brought out through the incision. Now with a wire being used as a guide, we were then able to perform an excision encompassing the area of concern. Specimen radiograph showed only partial area of concern and did not include all of the micro-calcifications……This specimen mammogram did confirm that we had the entire area of concern…
Original Charge Reported: 76098 Specimen Radiograph
APC Reimbursement Change: $183Units of Service: + 1
Specimen Charge is per Radiograph
Also Reported for Non-Breast Specimens
CholangiogramPROCEDURE IN DETAIL:
…The cystic duct was dissected free. A clip was placed on the gallbladder side of the duct. The duct was opened. A cholangiocatheter was inserted. Half and full strength cholangiogram was performed. There was an obvious filling defect… Cholangiocatheter was injected… There were no obvious defects….
Original Charges Reported: 76001 Fluoro <1 Hour and 74300 OR Cholangiogram
Cholangiogram
76001 Fluoro Over One Hour $0 74300 OR Cholangiogram $074300 OR Cholangiogram $0 74301 Add'l Cholangiogram $0
$0 $0
Original Charges Corrected Charges
APC Reimbursement Change: $0Units of Service: + 1
Intraoperative Cholangiogram are Reported Per Set (Injection)
ERCPPROCEDURE IN DETAIL:
The endoscope was inserted…cannulated the cystic duct…We then turned our attention to the pancreatic duct…cannulated the pancreatic duct…
Original Charges Reported: 76001 Fluoro <1 Hour and 74300 OR Cholangiogram
ERCP
76001 Fluoro Over One Hour $0 74330 ERCP Bile & Pancreatic $0$0 $0
Original Charges Corrected Charges
APC Reimbursement Change: $0Units of Service: + 1
ERCP has three RS&I Codes Available, Determined by Cannulation(s)
Biliary Duct Guide Catheter 74328 Cannula Pancreatic Duct 74239 Both Bile & Pancreatic 74330
JohnJohn’’s Guidance s Guidance
When someone asks what you did in surgery…your answer is what you should charge.
Fluoroscopy In Surgery 2 Hours (No RS&I to report)
Fluoroscopy In Surgery 3 Hours (No RS&I to report)
ARTERIOGRAQPHY Use ALL Appropriate RS&I VARIES Report RS&I Codes By Vessel(s) Imaged
BILE DUCT Biliary Duct Guide Catheter 74328 Pancreatic Duct Guide 74329 Bile & Pancreatic Guide 74330 Bile Duct Dilation 74363
BREAST OR TISSUE SPECIMEN Specimen Radiograph (each) 76098 Report for Each Radiograph
BRONCHOSCOPY Imaging Is Included STATISTIC Included In Bronoscopy - Use Statistical 'Charge' Percutaneous BX 77002 Once Per Lesion
Only Report One per OR Session
C-ARM CHARGE CROSSWALKNote: Charge for radiographs or c-arm images according to the number of views
ARTERIOGRAQPHY Use ALL Appropriate RS&I VARIES Report RS&I Codes By Vessel(s) Imaged
BILE DUCT Biliary Duct Guide Catheter 74328 Pancreatic Duct Guide 74329 Bile & Pancreatic Guide 74330 Bile Duct Dilation 74363
BREAST OR TISSUE SPECIMEN Specimen Radiograph (each) 76098 Report for Each Radiograph
BRONCHOSCOPY Imaging Is Included STATISTIC Included In Bronoscopy - Use Statistical 'Charge' Percutaneous BX 77002 Once Per Lesion
Only Report One per OR Session
C-ARM CHARGE CROSSWALKNote: Charge for radiographs or c-arm images according to the number of views
ERCP Biliary Duct Guide Catheter 74328 Cannula Pancreatic Duct 74239 Both Bile & Pancreatic 74330
FLUOROSCOPY Less Than 60 Minurtes STATISTIC Included In All OR Procedures- Use Statistical 'Charge' More than 60 Minutes 76001 Do Not Report With Radiographs Pacemaker 71090 Includes Fluoroscopy and Radiographs In OR Suite Central Venous Access 71001 Includes Fluoroscopy and Post Radiograph
GI TRACT Guide Intubation 74340 Includes Fluoroscopy and Radiographs In OR Suite Dilation Esophagus 74360 Includes Fluoroscopy and Radiographs In OR Suite
HIP Intraoperative 73530 Includes Fluoroscopy and Radiographs In OR Suite In Recovery (1 or 2 Views) 73560 Pelvis or AP & Lat
Only Report One of These Per OR Session
INTERVENTIONAL VASCULAR IMAGING - Use CPTs VARIES All Imaging Codes By Anatomy Visualized Angioplasty - Extremity 75962 Once Per Vessel Angioplasty - Add'l Extremity 75964 Once Per Each Additional Vessel Angioplasty - A/V Dialysis 75978 Once Per Vessel Angioplasty - Renal First 75966 Once Per Vessel Angioplasty-Renal Each Add'l 75978 Once Per Vessel Angioplasty -Venous 75978 Once Per Vessel Stent Placement - First 75960 Once Per Vessel Stent Placement Each Add'l 75960-59 Once Per Vessel Embolization 75894 Once Per Surgical Field Thrombolysis 75896 Once Per Surgical Field Thrombo Catheter Exchange 75900 Once Per OR Session Venography - Extremity (unilat) 75820 Once Per Extremity Venacavagram Inferior 75825 Not Reported With Cava Filter Plcmnt Venacavagram Superior 75827 Not Reported With Cava Filter Plcmnt
INTRODUCTION/GUIDANCE GI Tube (Miller Abbot Type) 74340 Includes Fluoroscopy and Radiographs In OR Suite Needle Biopsy 77002 Includes Fluoroscopy and Radiographs In OR Suite Percutaneous Drainage Tube 75989 Includes Fluoroscopy and Radiographs In OR Suite Spine Injections (Ndl Plcmnt) 77003 Includes Fluoroscopy and Radiographs In OR Suite
IVC FILTER PLACEMENT Cava Filter Placement 75940 Do Not Report Cavagram
SPINE Guide Catheter/Needle 77003 Disc or Vertebral Biopsey and Spinal Injections Discogram Cer/Thor (each) 72285 Report Per Disc Injected Discogram Lumbar (each) 72295 Report Per Disc Injected Kyphoplasty Thoracic (each) 72291 Report Per Vertebral Body Kyphoplasty Lumbar (each) 72291 Report Per Vertebral Body Vertebroplasty (each) 72291 Report Per Vertebral Body Biopsy Vertebra 77003 Report Per Vertebral Body Localization (or Single View) 72020 Spine Level Determination (permanent image)
URINARYCystourethroscopy, Diagnostic 74485 Fluoro Only - No FilmsLithoptripsey STATISTIC Included In OR Procedures- Use Statistical 'Charge'Lithoptripsey - US Ablation Renal 76940 US Ablation has an RS&I codeDilatation, Ureter or Urethera 74485 Diagnostic RPG requires modifier (-59) Retrograde Urography 74420 + Unilateral - Report Second Side With RT/LT (-50 or -59)
VENOGRAPHY Use ALL Appropriate RS&I VARIES Report RS&I Codes By Vessel(s) Imaged
SINGLE VIEWS Spine, Single View 72020 Per Imaging Order Joint, Single View 77077 Per Imaging Order
SPONGE COUNT Abdomen 74000 Once Per Exam Pelvis 72170 Once Per Exam Chest 71010 Once Per Exam
STRESS JOINT Fluoro Joint Under Stress 77071 Includes Unaffected Side
Arteriovenous Dialysis Interventions
Thank you for allowing me to spend some time with you today.
