Coding Resources and Reimbursement Guidelines Up-to-Date?
With the beginning of a new year it is important for radiology practices to ensure their resources are kept up-to-date. The following provides a listing of some of the pertinent resources and links for radiology practices so that you may take inventory and ensure you remain current and in compliance with various coding and policy guidelines. Be sure to consult original source documents, such as the Code of Federal Regulations, the Medicare Program Manuals, the Federal Register, and other authoritative sources for coding guidelines.
Current Procedural Terminology (CPT®) (also known as HCPCS Level I)
Current Procedural Terminology (CPT®) coding is the national standard code set to bill procedures and services to Medicare and other third-party payers. CPT code updates are released by the AMA, usually in October or November, and become effective the following January. Be sure to use only the most current code book as codes may have been deleted, new codes added, or descriptors and guidelines changed. Practices are urged to ensure codebooks, charge sheets and billing systems have been updated and ready for use the first of each year. Remember that the Centers for Medicare and Medicaid Services (CMS), no longer grants a 90-day grace period to update billing systems with new codes.
CPT Category I, II, III codes are also known as HCPCS Level I codes. Click here for more information on the differences between CPT Category I, II and III codes
Note: A listing of CPT Category III codes that became effective January 1, 2006, but are not listed in the CPT code book, can be found on the AMA Web site.
Health Care Common Procedure Coding System (HCPCS) Level II
HCPCS Level II codes are alpha-numeric codes established by CMS to describe items, supplies, and medical services not covered by CPT codes. These codes, used by Medicare, Medicaid, and private health insurers for claims processing, are updated on a quarterly basis (January, April, July, October). It is important to check the CMS Web site throughout the year for additions, changes, and deletions.
International Classification of Diseases, Ninth Revision, Clinical Modification, Sixth Edition (ICD-9-CM)
Physicians are required by law (Medicare Catastrophic Coverage Act of 1988) to submit diagnosis codes for Medicare reimbursement. CMS has designated ICD-9-CM as the coding system physicians must use. ICD-9-CM code updates are effective each October. To learn more about the ICD-9-CM coding process, go to the CMS Web site . The ICD-9-CM Official Guidelines for Coding and Reporting are on the Centers for Disease Control Web site.
National Correct Coding Initiative Edits
The National Correct Coding Initiative was established in 1996 to detect "unbundling" the submission of claims for each component of a service in addition to or instead of reporting a single, comprehensive code that includes all services provided. While there are code combinations that clearly are not acceptable under any circumstances, there are code combinations that are acceptable by Medicare and other payers when submitted with a modifier to designate a separate and distinct study.
CCI edit updates are implemented on a quarterly basis (January, April, July, and October) and posted on the CMS Web site . If you prefer a hardcopy manual of the CCI edit updates, several vendors provide this service.
CMS Web Site
The CMS launched a new Web site on December 15, 2005. The old CMS Web site addresses were to be automatically redirected to the new Web pages; however, many users have found that they are unable to locate the old Web address without searching. A number of the more frequently accessed CMS Web addresses are provided here for your convenience.
[Note: CMS is still in the process of converting some of their printed manuals (eg, carrier and fiscal intermediary) into online-only manuals. Links to the printed manuals are included here.]
For a complete listing of items listed under the Medicare home page click on Medicare. The following is a partial listing of issues that can be found under this title
Regulations & Guidelines
For a complete listing of items listed under the Regulations & Guidelines, click on Regulations & Guidelines. The following is a partial listing of issues to be found under this title.
Internet Only Manuals
#100-04 Claims Processing Manual
Paper Based Manuals
Fiscal Intermediaries Manual
HCPCS Release & Code Sets
Conditions of Participation & Conditions of Coverage
Quarterly Provider Updates
Search at the National Coverage Database
Transmittals (provides the latest information on new or changed Medicare policies before publication in CMS manuals)
Physician Resource Center
Survey & Certification
Medicare Physician Fee Schedule
APC Payment Rates
Note: Medlearn Matters – CMS provides online articles to health care professionals with the latest information on Medicare coverage and reimbursement policy changes. This site is updated daily, and these articles are issued in conjunction with Medicare program instructions (transmittals).
*For more information on National Coverage Determinations and a listing of some of the NCDs pertinent to radiology click here.
The ACR Economics and Health Policy Department offers coding guidance through a number of coding publications.
Practical and timely coding and reimbursement information is published in the ACR's bimonthly electronic newsletter, the ACR Radiology Coding SourceTM Each bimonthly issue is available on the ACR's Web site (free to ACR members) and offers a variety of useful and informative articles and updates (eg, feature articles on key radiology coding issues, latest information on Medicare and third-party payer policies and reimbursement, Correct Coding Initiative edits, and a Q&A corner). Continuing education units are available,which are accepted by the Radiology Coding Certification Board in support of RCC recertification. For the convenience of ACR members, a copy of the ACR Radiology Coding SourceTM feature coding article is reprinted in the ACR Bulletin.
The Journal of the American College of Radiology provides information on clinical parameters, practice management, education, health policy, and research on radiology health services. Practical tips on managing every aspect of a radiology and radiation oncology practice are given, including coding and reimbursement. Reference articles such as dictation patterns and their impact on billing, reimbursement risks with radiologist extenders, local payment policy, coding certification, and rationale for development of new codes (e.g., The New Reconstruction Codes: 3-D is Better Than No-D).
The ACR, in conjunction with the AMA, offers the AMA/ACR Clinical Examples in Radiology publication, a quarterly newsletter that provides carefully selected procedure reports, dissected and annotated by nationally recognized experts in radiology coding,with the goal to provide authoritative advice and guidance that is concise, practical, and of value in the day-to-day practice of radiology coders.
A number of printed and electronic coding guides are also offered through the ACR to assist radiology and radiation oncology practices in appropriate coding:
ASTRO/ACR Guide to Radiation Oncology Coding 2005
Interventional Radiology Coding Users' Guide 2006* (developed by the ACR, Society of Interventional Radiology, Radiology Business Management Association, and the American Healthcare Radiology Administrators)
Nuclear Medicine Coding User's Guide 2005
Ultrasound Coding Users' Guide 2006*
* Updates for 2006 are currently under review for the Interventional Radiology and Ultrasound coding guides and will be available for purchase spring 2006.
The above publications and coding guides, except for the Clinical Examples in Radiology, are available for purchase through the ACR Web site or by calling (800) 227-7762. To order the AMA/ACR Clinical Examples in Radiology, please call the AMA at (800) 621-8335, or order online at www.amapress.com.
Articles on Practice Management intended to help ACR members manage various aspects of the billing process, such as evaluating payer contracts, selecting a billing company, and diagnosing billing problems, are available on the ACR Web site. Practice management issues also are addressed by the Radiology Business Management Association on their Web site at http://rbma.org/ and in the bimonthly RBMA Bulletin.
The AMA's CPT Assistant (a monthly publication) and CPT Changes: An Insider's View(provided each year in conjunction with the new CPT codebook) offer additional insight into the creation and use of codes to help the coder better understand the intended use of a code. All AMA products may be ordered online at www.ama-assn.org or by calling (800) 621-8335.
ACR Committees and Networks
ACR Radiology Carrier Advisory Committee Networks
The ACR Radiology, Radiation Oncology, and Nuclear Medicine Carrier Advisory Committee (CAC) Network representatives advocate on behalf of radiology and all radiology subspecialties for fair reimbursement policies at the local Medicare level, by reviewing and commenting on local coverage decisions and policy changes before they are implemented. The CAC networks help to ensure members are appropriately reimbursed for medically reasonable and necessary services provided to Medicare patients.
To find your local Medicare Carrier, a link to their Web site, and local coverage decisions under development in your state go to the ACR's Web site.
ACR Managed Care Committee and Network
The ACR Managed Care Committee and Managed Care Network help ACR members deal effectively with issues related to private (non-Medicare) payers by: (1) determining member needs and developing responsive resources and services in response to those needs, (2) evaluating current and future payer trends and informing the membership of those trends, and (3) educating payers on the value of all radiologic modalities in providing costeffective care.
To find information on private payer coverage and reimbursement, including resources to address common coverage issues, practice management resources and information to help ACR members establish advisory relationships with payers in their state and educate payers on the cost-effectiveness of imaging utilization, go to the Managed Care/Private Payer section of the ACR Web site.
Radiology Business Management Association (RBMA)
The RBMA provides managers with information, resources, education and networking to run a successful radiology business. Seminars are specific to radiology and are designed to give practices proper coding and practice guidelines. The RBMA uses current, original materials from the ACR and other sources to ensure the radiology coding guidance is accurate and appropriate. The RBMA can be contacted at (888) 224-RBMA or visit their Web site at http://rbma.org/ to learn more about the RBMA.
Radiology Coding Certification by RCCB®
The Radiology Coding Certification Board (RCCB) offers a radiology-specific coding certification examination to coders and business managers.. The RCCB is independent of any other association or society and can maintain integrity concerning policy matters related to credentialing. RCCB-certified coders wishing to maintain certification must obtain 12 CEUs over two years or retake the exam. For details about the radiology coding certification exam, call (866) 227-7222 or visit the RCCB Web site at http://www.rccb.org/.
American Health Care Radiology Administrators (AHRA)
The AHRA serves radiology administrators and technologists by providing benefits including an extensive slate of conferences and seminars, an online database of all AHRA members, unique mentoring exchange programs, publications, and a List Server. Visit the AHRA Web site at www.ahraonline.org for a complete listing of benefits.
Other important specialty society Web sites that provide abundant information include:
For additional information on coding and reimbursement, visit the Reimbursement & Coding section of ACR Website.