Revenue Review

There is no more fat to trim now what?

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Radiology is a specialty that requires substantial capital expenditures. Therefore, it is important that in addition to continually monitoring the organization's expenses, the revenue portion of the equation should receive as much, if not more, attention.

The term "revenue enhancement" is defined by many organizations as the examination of the current charging structure with a specific emphasis on the identification of "missed revenue" opportunities. For some organizations, these projects yield substantial financial opportunities; however other organizations do not find the same results.

While revenue enhancement is certainly a goal of any coding/billing revenue, compliance and documentation should also be considered a key component. Regardless of your perspective – facility, physician or global – the making sure the physician's documentation clearly supports the codes being submitted is important in any situation.

Many payors are now requesting that the specific verbiage in the radiology report be underlined that corresponds with the billed codes when reports are appealed for additional payment consideration. It is imperative that you never request payment for services that are not adequately documented. Remember: If it isn't documented, it didn't happen.

When evaluating an organization's revenue potential, focus on the operational process that generates the charges, in addition to the charges themselves. Three key areas of potential opportunity are charge capture (charge tickets), code assignment and reject/denial follow-up. Inadequate performance in any of these areas can result in substantial revenue losses that severely impact the organization's financial position.

Charge Capture

The type of charge capture mechanism used in radiology is very dependant on the organization type and available resources. Hospital facilities generally use a Charge Description Master (CDM) that captures the procedures performed and provides the appropriate cross-references to ensure accurate billing. Freestanding facilities and physician practices generally rely on charge tickets or a similar charge capture mechanism, or individuals designated as coders perform this function.

Some physician practices rely on coding information obtained from the hospital's billing and/or radiology information system (RIS) system. If the CDM is not frequently or accurately updated, the information may be out-of-date or incorrect.

Unless good operational processes are in place, many times the hospital will bill what was entered into the system as being scheduled and not exactly what was performed. Examples include billing contrast studies inappropriately, either assigning a "with contrast" study as "without contrast" or vice versa and assigning an incorrect code because the correct study was not scheduled (e.g., UGI was scheduled, but only an esophagram was performed).

Many times the hospital will charge multiple CDM line items and use bundling software to adjust as needed prior to sending a claim. If the physician practice does not use similar mechanisms, unbundling can occur. For interventional procedures, there is a great chance that many charges are missed by the physician if only hospital information is used.

Regardless of the method used for charge capture, it is important, at a minimum, to evaluate the following: n Are the codes and descriptions listed on the charge ticket accurate and up-to-date? n Have the necessary system changes (updates) been implemented to ensure accuracy code submission? (e.g., are the new central venous catheter codes in the computer system?) n For facilities, are there CDM numbers for all procedures currently performed in the department? n If the CDM numbers are not in place (yet) and the billing department is making manual changes prior to submission, what guidelines are being used to ensure accuracy?

Code Assignment

Performing the medical coding function for radiology consists of assigning the accurate procedure code for the service(s) rendered. In addition to selecting the correct procedure code(s), the correct diagnosis code(s) must also be determined after the completion of the exam.

The majority of physician practices have designated medical coders to perform this important function. Hospital facilities tend to either (1) make the technologists responsible for the CDM number selection/entry after the completion of the exam, (2) use the information generated during the scheduling process or (3) have designated medical coders perform some or all of the charge capture/ coding function.

Assigning medical codes has evolved from a clerical function to the responsibility of a coding professional. Staying on top of the coding industry requires individuals who seek continued professional improvement and expanded knowledge. The coding and compliance rules are constantly changing and discerning the impact of these changes is not always a small task.

• Regardless of the method used for code assignment it is important, at a minimum, to evaluate the following:
• What individuals or system processes impact the code assignment and at what point in the process?
• What information is being used for code assignment? Dictated report, scheduling information, order, etc?
• Is the information being used accurate and defensible in an external audit?
• When and how are modifiers assigned in the coding process? What information is used to ensure accurate assignment?
• Does the physician documentation clearly support the procedure and diagnosis codes being assigned from both a facility and physician perspective?
• What coding tools are used by the individuals responsible for coding? Are they up-to-date, accurate and reliable?
• Have the Local Medical Review Policies (LMRP) for your carrier/fiscal intermediary been reviewed to ensure an understanding of medical necessity requirements?
• Are key radiology add-on codes used accurately? (e.g., are the CPT codes 75774, 36218 and 36248 assigned when appropriate?)
• Are bundling edits accurately followed and bypassed when appropriate? For example, selective catheterization of multiple vascular families generally require modifier assignment since the payor bundling edits do not take into account the concept of vascular families.

Rejects/Denials

Claim denials due to coding concerns or medical necessity have been a challenge for physician practices for years. Denials for outpatient radiology hospital procedures have increased and many organizations have not found a way to effectively evaluate and manage this process which has resulted in lost revenues to the organization.

Communication between the business office (sometimes referred to as Patient Financial Services, or PFS) and the radiology department is critical to ensure that rejections and denials due to medical necessity or coding concerns are properly addressed and not inappropriately "written off." The guidelines used for interventional radiology code assignment are complex. Without an understanding of these guidelines, individuals can incorrectly assume that duplicate charges were created, modifiers were inappropriately assigned and/or that charges were incorrectly created by the department of radiology.

While charges sometimes do get incorrectly created by the radiology department, there needs to be clear communication to ensure an appropriate check-and-balance system for write-offs and appeals.

Example starting points for a radiology reimbursement review:

• selective catheterizations and corresponding angiography – codes: 36215-36218, 36245-36248 and 75705, 75722, 75726, 75741, 75743, 75774. Many payors will place limits on the number of selective catheter placements and/or angiography studies that will be reimbursed per case without regard to individual medical necessity. While appeals are at times successful, many times they are rejected as "bundled" or "exceeds frequency limitations." In many healthcare entities, complex cases are performed that require additional catheterizations; therefore, standard frequency limitations are inadequate. Examples include multiple spinal catheterizations and highly complex cerebral catheter placements.
• breast procedures – codes: 10022, 19100, 19290, 19102, 19103, 19000, 19001. These codes are intended to be used per occurrence, i.e. per lesion or per cyst. Many payors will place frequency limitations on the utilization of these codes without regard to the number of lesions, cysts, etc. Check to see if you are being reimbursed per lesion or cyst and for the imaging guidance for each area being treated.

Ultimately, payors will set their own policies and contracted providers will be obligated to follow them. However, revenue that is due to the organization should not be left on the table unnecessarily. Arm yourself with good information and don't cut into the muscle of the organization until you have exhausted an evaluation of the revenue side of the equation.

— Melody W. Mulaik, MSHS, CPC, RCC, is president of Coding Strategies Inc., Powder Springs, Ga. Questions and comments can be directed to editorial@rt-image.com.