Several regulatory changes affect radiology practices every year. The business of radiology has become increasingly complex as regulatory demands increase and reimbursement declines. Diagnostic radiology and laboratory testing are often scrutinized for healthcare fraud schemes. In today’s audit scenario, radiology practices and the medical billing companies that serve them need to take steps to stay on top of compliance issues. Here are best practices to succeed in the ever-changing regulatory landscape and stay audit-ready.
- Report radiology services correctly: Each year, changes are made to Current Procedural Terminology (CPT) codes relevant to radiology. For instance, in 2017, there were changes in bundled mammography, the addition of imaging to dialysis and balloon angioplasty bundles, changes in fluoroscopic guidance codes, and alterations to the spinal injection codes. Practices need to review the new, deleted and revised codes before they come into effect. Experienced coders in a medical coding company are well aware of stay ahead of these updates as they are well aware of the resources available to help radiologists stay current with CPT updates and report their services correctly.
- Ensure documentation to support medical necessity: A complete and accurate test order is critical as Medicare pays only for services that are reasonable and medically necessary. Supporting documentation of medical necessity of the service provided by the radiologist should include relevant and/or current records from the physician’s office, such as office notes, history and physical, labs, etc. if applicable. There should also be documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) or coverage article for service(s) billed, if applicable and Advance Beneficiary Notice of Noncoverage (ABN), if applicable. Providers should read all NCDs and LCDs for services provided to make sure all documentation requirements are met.
- Know the rules for the setting: Hospitals and physician practices are governed by the Medicare Conditions of Participation. However, the rules for diagnostic test orders differ between an office-based practice and an independent diagnostic testing facility (IDTF). The Medicare Conditions of Participation for hospitals states in 42 CFR 482.26, “Radiologic services must be provided only on the order of practitioners with clinical privileges or, consistent with State law, of other practitioners authorized by the medical staff and the governing body to order the services.”
According to the physician conditions of participation in 42 CFR 410.32, all diagnostic tests must be ordered by the treating physician. The treating physician is defined as one who ,furnishes a consultation or treats a beneficiary for a specific medical problem” and “uses the results in the management of the beneficiary’s medical problem.”
Knowing the specific requirements for diagnostic test order that apply to the setting is therefore important. The rules for IDTFs are particularly stringent due to a history of fraudulent billing practices where such facilities routinely added tests that were not ordered or not medically necessary. Finally, regardless of the type of setting, it is the responsibility of ordering physician to document medical necessity for a test order.
- Know why the test was referred: To register a patient for diagnostic services, the referring physician should provide radiology documentation of clinical information to the interpreting physician. An AAPC report reminds us that ICD-10-CM guidelines clarify 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.
- Scrutinize physician documentation: Diagnostic radiology covers a wide range of services, from diagnostic radiology (plain film), diagnostic ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) to diagnostic nuclear medicine, positron emission tomography (PET), and mammography. In addition to requiring a valid order from the patient’s treating physician, all radiology services must be patient-specific, encounter-specific, clearly indicate the exam requested by the treating physician, and include the reason for the study. To meet ACR guidelines, dictated radiology reports should meet minimum requirements and contain:
- Heading (study name);
- Number of views or sequences (name of views – what was done)
- Clinical indication (reason for exam)
- Body of report (findings)
- Impression or conclusion (synopsis of findings)
- Physician signature
- Diagnostic studies (plain films)
It is important that providers are knowledgeable about the ACR diagnostic imaging report and signature guidelines to ensure compliance and face audits with confidence.
As a best practice, all documentation and coding should all be reviewed periodically to ensure that the practice is well-positioned to face an audit or investigation if one should one occur. With all the complexities involved in reporting their services, getting expert support from an experienced radiology medical coding company could be the best strategy to maximize compliance and avoid potential penalties. Skilled coders are experts at identifying discrepancies, contradictory statements, and documentation that do not match the patient’s clinical picture. Other benefits of outsourced medical billing and coding services for radiologists would include updates on coding changes and regular feedback about appropriate coding opportunities to maximize reimbursement.