October 2014

Radiology Billing and Coding: Tips To Avoid OIG Work Plan Scrutiny
By John Verhovshek, CPC
Radiology Today
Vol. 15 No. 10 P. 6

Each fall, the Office of Inspector General (OlG) creates a Work Plan to set investigative priorities for the coming year. Health care providers should pay special attention to these priorities because they relate to compliance issues under investigation, such as potential fraud and abuse violations. The 2014 OIG Work Plan includes two radiology-related items:

• Diagnostic radiology—Medical necessity of high-cost tests: “We will review Medicare payments for high-cost diagnostic radiology tests [eg, PET scans, CT scans, and MRIs] to determine whether they were medically necessary and the extent to which utilization has increased for these tests.”

• Portable X-ray equipment—Supplier compliance with transportation and setup fee requirements: “We will review Medicare payments for the transportation and setup of portable X-ray equipment to determine whether payments were correct and were supported by documentation. We will also assess the qualifications of the technologists who performed the services and determine whether the services were ordered by a physician (eg, doctor of medicine or doctor of osteopathy).”
The full document is available at http://oig.hhs.gov/reports-and-publications/workplan.

To avoid being caught in the OIG’s dragnet, radiology practices must furnish only those services ordered by qualified providers and ensure that ordering providers document all information necessary to establish medical necessity for services performed.

Specifically, Medicare will cover radiology services only by order of a qualified health care provider. Per the Centers for Medicare and Medicaid Services (CMS) Transmittal AB-01-144, the referring provider’s order may take several forms, as follows:

• a written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;

• a telephone call by the treating physician/practitioner or his/her office to the testing facility. (Transmittal AB-01-144 further specifies, “If the order is communicated via telephone, both the treating physician/practitioner or his/her office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical record.”); and

• an e-mail by the treating physician/practitioner or his/her office to the testing facility.

To substantiate the need for the service, the ordering provider’s supporting clinical information should include multiple items, such as his or her name, signature, address, phone/fax numbers, specialty, and tax identification number, to ensure accuracy. The ordering provider may be the patient’s treating physician or other approved health care provider. By law, a licensed physician must order portable X-rays; however, the OIG found that, in 2009, Medicare paid approximately $6.6 million for portable X-rays ordered by nonphysicians. Such claims have come under increased scrutiny under the current OIG Work Plan.

The reason for the procedure performed (eg, the patient’s signs and symptoms) is also important and should be documented. Medicare national and local coverage determinations typically specify which diagnoses will support a specific imaging or testing procedure. The selected diagnosis codes should accurately reflect the patient’s condition. Referring providers should avoid language such as “rule out” or “possible,” which may be interpreted as ordering a screening or preventive service (unless that is the order’s specific intent). With few exceptions, Medicare does not cover preventive or screening services. Instead, the ordering provider should report the precise signs and symptoms that prompt the order for the radiology service.

Per CMS Transmittal AB-01-144: “On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.”

Additionally, Medicare rules do not allow for additional imaging studies beyond those requested by the ordering provider (except in cases of medical emergency). For example, if the treating provider orders an abdominal CT scan for right lower quadrant pain with suspected appendicitis, you may not add a CT of the pelvis without obtaining a new written order.

Practices should also use caution when provided with conditional orders. For example, a written order might state, “Abdominal ultrasound for abdominal pain. If negative, abdominal CT scan.” Such orders may be used on a case-by-case basis when medically appropriate, but because of the potential for abuse, these orders should not be routine.

Finally, note that providers who self-refer are under especially intense scrutiny to establish medical necessity for services ordered. The Government Accountability Office, among others, has determined that physicians who own their own diagnostic imaging equipment are more likely than those who do not own their own equipment to refer patients for tests, according to a report released in 2012 (http://www.gao.gov/products/GAO-12-966).

— John Verhovshek, CPC, is managing editor for AAPC, the nation’s largest training and credentialing organization for the business side of health care.