Documentation and reporting are keys to getting reimbursed
By C. Matthew Hawkins, MD Fall 2016
Running a profitable IR practice is increasingly challenging. The margins for both hospitalbased and non-facility-based practices continue to shrink as procedural reimbursement declines and, in many instances, practice expenses increase. Fairly recent initiatives from the Centers for Medicare and Medicaid Services (CMS), such as code bundling, are forcing IR practices to examine all aspects of their business in an effort to decrease waste and increase efficiency.
One simple first step to improve financial solvency and efficiency is optimizing clinical and procedural documentation. Armed with systematic documentation, coders can appropriately report actual services performed and easily increase reimbursement for both clinical and procedural services. Optimized reporting will also become essential as we begin reporting to national registries in compliance with recent health care legislation.
The reimbursement process
The entire reimbursement process begins by reporting clinical justification for clinical and procedural services provided for patients. The International Classification of Diseases (ICD) is published by the World Health Organization and maintained/revised by the National Center for Health Statistics.1 The 10th revision (ICD-10) was recently adopted in the United States. ICD-10 codes describe the medical condition and justify the necessity for subsequent medical/procedural services. Reporting appropriate ICD-10 codes is the first step in procuring appropriate reimbursement for services provided. If there is insufficient clinical history or inaccurate ICD-10 reporting, it is very likely that reimbursement will be delayed or denied, regardless of the procedure that was performed. This scenario is commonly encountered for central venous access procedures. It is not uncommon for referring providers to list “needs central access” as an indication for the requested procedure. However, there is no associated ICD-10 code for this indication, and thus, more in-depth clinical justification (e.g., pneumonia, lung cancer, etc.) is required for reimbursement.
After justifying the clinical need for a procedure with ICD-10 codes, practices must accurately report what procedure was performed via Current Procedural Terminology (CPT) codes. This code set is maintained by the American Medical Association (AMA) CPT Editorial Panel, composed predominantly of physicians nominated by specialty societies. CPT codes are chosen from the code set on the basis of the technical parameters of a procedure and the description of the procedure provided in the procedural report.
After justifying the clinical need with ICD-10 codes and reporting services provided with CPT codes, the value (relative value units; RVU) for these services is determined by the Resource-based Relative Value Scale (RBRVS). This scale is periodically updated by the AMA Relative Value Scale Update Committee (RUC). In short, RVU value recommendations from the RUC are often adopted by CMS for Medicare reimbursement. These values have substantial influence on negotiated reimbursements from private insurers, although geographic and carrier variation exists. Furthermore, RVU recommendations from the RUC are heavily determined by data collected from RUC surveys, which ask members to provide information related to the time and effort required to perform various clinical duties and procedures. SIR members are encouraged to actively participate in these surveys, as the survey data is critical to our society’s ability to argue for appropriate reimbursement for the work that we do and gives all SIR members a voice in the reimbursement process.
How documentation impacts reimbursement
Consider the following clinical scenario:
A 32-year-old female presents to IR for increased risk of postpartum bleeding. Placement of bilateral internal iliac artery occlusion balloons is performed. Inflation in the IR suite was performed to confirm position. The patient is then transferred to the operating room and proceeds to have a safe cesarean section. The arterial sheaths are removed the following day and the patient and her infant are discharged home 72 hours later.
Documentation will impact the reimbursement for these IR services in several ways. First, what was the clinical indication for the procedure? Why was there an increased risk of postpartum bleeding? Was there placenta accreta? The chances of justifying the clinical need for the procedure increase as more specific clinical detail is provided.
Second, was diagnostic angiography performed? By clearly stating that the bilateral iliac arteries were selectively catheterized and describing the angiographic findings, such as increased placental vascularity, and/or the vascular supply of the placenta, a diagnostic angiographic study (CPT 75736) may be justified. Simply stating that “the placental vessels were seen” or “diagnostic angiography was performed” does not justify reporting a diagnostic angiogram but rather describes roadmapping and guidance that is included in the embolization codes (37241–37244). The bottom line is that to report a diagnostic angiography code, findings of the angiogram must be delineated.
Third, inflating the balloons only to confirm positioning does not justify reporting an embolization code. If the IR accompanied the patient to the operating room and inflated the balloons during or prior to the cesarean section, then an embolization/occlusion may be justified—but it must be clearly stated.
Finally, if appropriate clinical reasoning for why arterial sheaths were removed the following day is documented, it would be appropriate to report E&M codes for that service since the catheterization and embolization codes have a zero-day global period and do not include clinical work provided on subsequent days.
While there are a number of additional coding nuances to this complex case, I hope you see the importance of thorough documentation to appropriate reimbursement for services. If the documentation is poor, payment may be denied for all services. Conversely, thorough documentation may justify reimbursement for diagnostic angiography, arterial embolization, internal iliac artery selective catheter placement and subsequent E&M services for sheath removal.
Documentation of evaluation and management (E&M) services
Although our specialty and SIR have long encouraged interventional radiologists to embrace the clinical nature of our specialty, there are still many IR practices that do not have outpatient clinics and/or inpatient clinical service documentation processes. These components of an IR practice serve to document key medical decision-making in the complex clinical scenarios that IRs routinely encounter, in addition to improving IR’s reputation with other specialties and referring providers. However, they also can serve to improve the financial performance of an IR practice.
Kwan and Valji have written about how E&M providers have higher total procedural charges and obtain higher charges per unit of procedural work performed.6 White et al. also showed that a systematic approach to reporting inpatient E&M services can improve the number and complexity of inpatient encounters.7 Additionally, thoroughly documented clinical encounters allow opportunities to adequately document the clinical need that justifies subsequent procedures.
By taking care of adequate clinical justification on the front end, payment approval (and often preapproval) is more likely. Thus, your financial management team will spend less time laboring to procure payment for procedures for which reimbursement is initially denied because of inadequate clinical documentation.
Structured reports and national registries
There are a number of financial motives, as described earlier in this article, for refining and optimizing the documentation and reporting process for IR practices. But in light of recent health care legislation (Medicare Access and CHIP Reauthorization Act of 2015; MACRA) and with an eye on impending mandated payment policy changes, the need for thorough clinical and procedural documentation will only intensify.
Whether participating in the Merit-based Incentive Payment System (MIPS) or Alternative Payment Models (APMs), thorough documentation will be required to receive appropriate payment. This legislation substantially alters the reimbursement paradigm in health care by paying physicians for quality and value, rather than on a transactional basis—the current practice. A thorough review of these payment models and their impact on interventional radiology has been formulated by our society (read an overview of MACRA).8
Regardless, nationwide data to perform comparative effectiveness research, track patient outcomes and measure value will only come from a specialty-wide commitment to registry reporting and adoption of structured reports for commonly performed IR procedures.
To this end, SIR has established the IR National Quality Registry in collaboration with the American College of Radiology (ACR). This registry is a CMS Qualified Clinical Data Registry (QCDR) and allows IRs to fulfill CMS’ quality reporting requirements via electronic health record extraction and/or structured report adoption. These structured reports, produced by SIR and SIR Foundation, are designed to efficiently populate registries such as the National IR Quality Registry. Following a successful nationwide pilot study of these structured reports, the next generation of reports is currently being developed for nationwide dissemination. Read more.
Whether optimizing current transaction-based reimbursements or planning for value-based payments, an emphasis on thorough clinical and procedural documentation is necessary for all IR practices. All practice leaders will be well-served by examining current documentation and coding practices and by joining nationwide efforts to set our specialty up for success with future payment models.
- Lam DL, Medverd JR. How radiologists get paid: Resource-based relative value scale and the revenue cycle. AJR 2013; 201:957–958.
- Radiology Coding Certification Board. rccb.org. Accessed on July 4, 2016.
- Levinson D. Improper payment for evaluation and management services cost Medicare billions in 2010. Department of Health and Human Services; Office of Inspector General 2014.
- Phillips CD, Hillman BJ. Coding and reimbursement issues for the radiologist. Radiology 2001; 220:7–11.
- National Health care Fraud Takedown Results in Charges Against 301 Individuals for Approximately $900 Million in False Billing. The United States Department of Justice. June 22, 2016. justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-301-individuals-approximately-900. Accessed on July 4, 2016.
- Kwan SW, Valji K. Interventional radiologists’ involvement in evaluation and management services and association with practice characteristics. J Vasc Interv Radiol 2012; 23:887–892.
- White SB, Dybul SL, Patel PJ, et al. A single-center experience in capturing inpatient evaluation and management for an IR practice. J Vasc Interv Radiol 2015; 26:958–962.
- MACRA Matters: What you need to know. Society of Interventional Radiology. sirweb.org/clinical/macra.shtml. Accessed July 4, 2016.
The CPT code set is complex with many exclusionary parentheticals, formatting oddities and contentspecific jargon that can make interpretation of its content challenging. It is important for practices to have expert coders who are proficient with the CPT manual, interventional radiology procedures and practices.
Interventional radiology is often considered the most challenging specialty to report procedural services for because of the breadth of services we provide, variability in code structure (ranging from procedures that are entirely reported by a single bundled code to procedures that are reported by component coding) and annual code changes (new or edited codes). In this respect, it would be wise for practices to evaluate the expertise of their current coders and see if they have added qualifications for interventional radiology coding.
As many radiology coders have only diagnostic radiology coding experience, it may be unfair to expect optimal CPT coding from individuals who do not have additional training or expertise in IR. Certain coding certification programs, such as the Radiology Coding Certification Board2, have in-depth interventional radiology coding training that may help practices improve CPT coding for their practices.
Cost of noncompliance
Why can’t our coders just code for what was actually done, even if it is not clearly stated in the report? Although this practice may have been common once, multiple national regulatory bodies have increased their focus on proper coding and compliance.1
A recent report from the U.S. Department of Health and Human Services Office of the Inspector General showed that there were $6.7 billion in E&M codes incorrectly coded or lacking appropriate justification in 2010 alone, representing 21 percent of all Medicare reimbursements for E&M services.
Furthermore, the definition of fraud (as it pertains to coding) includes intentional or systematic incorrect billing practices for the purpose of inflating reimbursement, including honest errors and unintentional practices.4
The recent Medicare Strike Force in 36 federal districts resulted in criminal and civil charges against 301 individuals, including 61 physicians for fraud schemes that resulted in greater than $900 million.5
In the current milieu, coding and billing must reflect what was documented and must comply with existing coding guidelines.
A strong presence
The CPT Advisory Committee is composed of representation from professional societies spanning all sectors of health care. The SIR CPT advisory team currently includes Timothy L. Swan, MD, FSIR, Waleska M. Pabon-Ramos, MD, MPH, Ammar Sarwar, MD, and Matt Hawkins, MD—in addition to many dedicated and skilled SIR staff led by Robert White. Our specialty is further represented on the CPT Advisory Committee by SIR members Daniel Picus, MD, FSIR, and Timothy Crummy, MD, who serve as the CPT advisors for the ACR and RSNA respectively. SIR is also represented on the RUC by Michael Hall, MD, and Gerald A. Niedzwiecki, MD, FSIR.