Radiology RACs: Get ready to rumble

by guest-author Richard M. Chesbrough, M.D.
Board-Certified, American Board of Radiology
Medical Director, RadMetrics™


Now that CMS has begun using Recovery Audit Contractor (RAC) auditors to review hospital-based medical care and durable medical equipment providers, auditing of radiology services is on the immediate horizon. In fact, the OIG has placed radiology audits on their 2010 work list. Forward thinking providers and healthcare systems are preparing now, to formulate compliance plans for diagnostic radiology services.

One area of radiology review will be documentation and proper coding of imaging procedures. CMS and OIG audits will likely include evaluation of the referring physician’s order, appropriate CPT coding of the procedure, documentation of medical necessity and a separate written report for each study billed.

The following are compliance issues that providers should consider, in preparation for RAC auditing of radiology services:

1. Physician Order: Is there appropriate documentation that a treating physician or practitioner requested the specific diagnostic test performed? This is an absolute requirement for reimbursement. Records must be maintained by the billing entity, in order to avoid potential conflict.

2. Coding: Based upon review of images and documentation, is the coding correct and proper CPT coding utilized? For example:

• a complete abdominal ultrasound is provided, but only the liver and gallbladder are imaged. Therefore, only a limited study should be billed.
• a radiological examination consisting of 2 views is provided, but a “complete” radiological examination consisting of a minimum of 5 is was billed.

3. Medical Necessity: Studies must not only be ordered and coded correctly, but they must be medically necessary - used in the care and treatment of the patient. Studies or procedures that are not indicated may be viewed as not reimbursable, and/or subject to recoupment of paid claims. For example:

• A CT scan is provided without contrast followed by with contrast. However, based on the patient’s condition, only a CT scan with contrast was indicated. Not only does this represent over-coding (wrong CPT code), but the patient has received twice as much radiation as medically necessary.
• Billing for 3-D reconstructions on CT Scans, performed without documentation of medical necessity or separate physician order. In addition, reconstructions must be performed on a separate workstation, and noted in the final written report.
• Screening procedures: Ultrasound of the abdominal aorta ordered to screen for aneurysm. However, the patient does not meet appropriate Medicare (or national standards) screening criteria.

4. Imaging Report: Auditors will undoubtedly be reviewing procedures to see that a formal written report has been issued, for cases where there is billing for the professional interpretation (professional component). Such reporting is mandated by;

• AMA guidelines
• CMS / Medicare regulations
• American College of Radiology
• American Association of Orthopedic Surgeons
• Many other professional organizations

The RACs are coming and it’s time to get into compliance. Medical imaging is one of the areas of great interest, and healthcare providers are well advised to get their policies and procedures in order, and to review their compliance programs in radiology.

CMS Update: 13 New Quality Measures

CMS has adopted 13 of their 43 proposed new quality measures for FFY 2010. One measure, pneumonia oxygenation, has been retired, bringing the total to be reported to 42 (full list of CMS quality measures).

Two additional measures are expected to be approved next year, bringing the total up to 44. These are AMI and Pneumonia Readmit rates. Enovasis analysts expect one new measure in particular may be of concern for many hospitals: The Heart Failure 30-day Risk Standardized Readmission Measure.

According to MedPac, readmissions cost Medicare $15 billion every year—$12 billion of which is believed to be preventable. Almost 18% of Medicare patients are re-admitted to a hospital within 30 days of discharge. The Heart Failure re-admission measure, to be calculated automatically using Medicare claims data, may prove to be a source of many improvement efforts, time and resources. With this information becoming publicly available, hospitals should start monitoring and improving this rate as soon as possible.

Many hospitals have initiatives to reduce length of stay in the high-volume, high-cost heart failure category, but few monitor the repercussions of those initiatives closely. One major repercussion being a high readmission rate. If this rate is high at your hospital investigate your use of home care or other post-discharge treatment. Also analyze readmits by discharge day of the week or by post-acute provider to find clues as to what is causing returns.

Contact Enovasis Healthcare Solutions if you need assistance.