Monday, April 21, 2014
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Last September, I wrote about growing your practice through offering Ankle–Brachial Index (ABI) screening for adults at risk for Peripheral Arterial Disease (PAD). In my honest opinion, during these trying times of reduced reimbursements (and until all radiology payments shift to value based payments), we should be considering how to legitimately offer new services to support our radiology practices, imaging centers, and hospitals.

Under the new Affordable Care Act (Obamacare) when the U.S. Preventive Services Task Force (USPTF) recommendation reaches an A or B; Medicare is then obligated to lungscover and pay for the service. This now appears to be the case as Lung Cancer Screening with Low Dose Computed Tomography has the USPSTF "B" recommendation rating as of July 30, 2013.

CMS has completed their process of soliciting comments for covering this screening service. They were primarily interested in evidence to determine:

1.) Identification of patients eligible for screening

2.) The appropriate frequency and duration of screening

3.) Facility and provider characteristics that predict benefit or harm

4.) Precise criteria for test positivity and the impact of false positive results and follow-up tests or treatments.

As of the March 12, 2014 closure date for submitting comments CMS received around 400 responses. Comments came from individuals with family history to expert researchers and included representatives from cancer centers, thoracic physicians, and professional societies/associations.

lungscreen1While I expected everyone to be supportive, there were those who were in opposition. The most obvious uninformed comment that I read was, "The Lung Cancer Screening with Low Dose Computed Tomography process, as it exists, is already a cash cow. Why feed it? It is functioning well on its own." Obviously, this person has no clue that there is currently no screening program on the books! Conversely, there was another individual who recognized the social-economic element, "Because lower income, less educated populations remain the last major demographic population that still smokes heavily; and this is the same population that this early screening could help really save substantial lives". Finally, a more informed commenter stated that patient education on smoking cessation should be part of this process.

The CMS Proposed Decision Memo Due Date is scheduled to be published on November 10, 2014. Mark your calendars! In the meantime, those practices that believe in the value of this service and the likelihood of coverage can begin putting a marketing plan together now for rolling out a screening program. Commercial carriers will likely be forced to follow suit and cover this service, too. And as I say this, I personally never expect this type of service to compare to the success of breast cancer screening.

In composing this article, I spoke with my own local primary care physician on his perspective of this matter. What I found revealing is that his initial comment was that he would likely not be among the first to start ordering these screening tests. Knowing customer objections is important to any marketing plan! He was initially concerned with radiation exposure and what the frequency might be for follow up studies. Second, he was concerned over the potential of false positives and related clinical care from the pulmonologists. His concerns included collapsed lungs, challenging lung biopsies, and unnecessary surgeries. All valid concerns and being evaluated by CMS! And while I am repeating myself, it is important to perform in-depth marketplace research for how your customers may accept the new service.

His final comments were actually the most compelling. He shared with me his experience in referring patients to a local radiology group for abdominal aortic aneurisms (AAA) screening. As most of us know, Medicare currently pays for one screening ultrasound for new Medicare beneficiaries who are at clinical risk for AAA. That said, he was asked by the radiology group to refrain from ordering these screening studies as Medicare is not paying for this service. This led our discussion to proper CPT procedure and ICD-9 (10) diagnosis coding along with denials management process of the group. But I will leave that topic for a future blog. Please feel free to contact me at any time at This e-mail address is being protected from spambots. You need JavaScript enabled to view it for more information.

lungcancer


ABOUT THE AUTHOR

Photo of Steven SchrieberSteve Schreiber is a Senior Management Consultant at IMAGINE Software. Schreiber has 24 years of medical practice management experience with the emphasis being in radiology. He has managed hospital-based and combined hospital/imaging center practices in highly competitive environments and has been an active member of RBMA since 2002. He is currently serving on the Board of Directors, past Parliamentarian, Vendor Relations Committee chair and as a member of various other committees. The RBMA has recognized Schreiber in the 2013 class of RBMA Fellows and has also presented Schreiber with special recognition awards in both 2005 and 2011 for his contributions to the RBMA practice management forums.

Blog - IMAGINE Management Team

I’ve spent a lot of time recently talking about Order Verification in IMAGINE.  What it means, how it’s used, why it’s important. 

What I find interesting is how many people aren’t sure what Order Verification is or what it means in IMAGINE, but once I start explaining, it’s like a light goes off and then the person goes “Oh, you mean log checking” or “Wait, are you talking about hospital audits?” or “Oh my gosh, do you mean you can automate log file validation?”.

YES!!!  Yes, we can!  We do!  We will! 

yoda

I feel like a Dr. Seuss character. 

Or maybe Yoda – “Help you, help you I will”. 

Help you I will…if you’ll let me.

Order Verification is the same thing as log checking, log file checking, audit file checking, order validation, anything else you want to call it.  Order Verification happens when you take an electronic file containing a list or schedule from outside IMAGINE and bring it into IMAGINE.   IMAGINE will then take that list and go search for matches inside your billing database. 

We check three areas within IMAGINE: posted charges, unposted charges, and deleted charges.  If we find a match in ANY of these areas, we’ll flag the record from the audit file as ‘MATCHED’ and show you where we found it.  If we DON’T find a match, we’ll flag it as ‘UNMATCHED’ and show you that as a separate list.  The whole thing is built into a workflow screen that is already present inside of IMAGINE.

So, what's the catch? Well, there is one really important trick to this that I don't control – you have to have an electronic file containing this list of orders or visits or whatever it is you can use for independent verification to be able to then load it into IMAGINE for searching. If you already know that you have or can get a file like that, awesome! Terrific! Wonderful news! You can start loading the file immediately with our standard Order Verification interface or, if it's in a slightly different format, you can talk to us about the file type you have and we can program an interface to match. If you don't have a file like this already on hand, DON'T WORRY. Chances are we can help you find one – we've got plenty of experience working with hospitals and other scheduling systems to facilitate this.

In the end, Order Verification is truly the ultimate time saver for making sure the correct charges have been accurately captured for all services, helping to reduce the errors, duplicates, denials, and unpaid claims that equal more frustration and less money for your business.

Let's work together – contact IMAGINE today and find out how to take advantage of the Order Verification interface as well as the many, many other key features in our system that can benefit your practice.


ABOUT THE AUTHOR

chrisf

Chris Fitzgerald has been with IMAGINE Software since 2005, working to ensure customer satisfaction through support maintenance, continuing education programs, and on-going customer relations for IMAGINE's number one focus - its clients.  He currently serves as Vice President of Product Management, where he continues to leverage his experience with customers and their needs to constantly improve the IMAGINE Suite of products.

Contact This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Blog - IMAGINE Management Team

There has already been a lot written about ICD-10 implementation coming October of this year. Unlike so many other government initiatives, I do not believe that this one will be postponed. So, if you tend to procrastinate, please don’t!  The rest of the developed nations have already complied with the World Health Organization’s need to collect and analyze healthcare information.  And while this is an honorable goal, many of us fear that 3rd party payers will use this event as another opportunity to somehow delay or reduce payment to providers.

As my years of experience and vested interest center around radiology, I would like to focus this editorial on impacts to this battered medical specialty. Radiology practices are highly dependent on intake information obtained by a hospital partner or referring practitioner. The radiologist and their teams (receptionists, schedulers, billers, coders, technologists, and administrators) have to pay extra close attention to the information at the front end of the workflow process to avoid backend delays, hassles and reduced revenues.

Coders know that it is fraudulent billing practice to uses codes that are not supported by the radiologist’s report.  Increasingly asking a coder or biller to contact a referring physician for a correct code after the patient left will result in poor customer relations with referring clinicians and their staff. Everyone needs to address this at the forefront.

So, how do I know that this is a real issue for radiology?  I did my homework and reviewed the top 50 diagnosis codes used in 2013 by radiology practice clients.  This is an exercise that I recommend all radiology administrators perform.  Here are some examples of what I found:

 

Example #1

5% of all patients seen in 2013 had a diagnosis of 789.09. There are three new codes to replace this code.

ICD-9 Code

ICD-10 Codes

789.09 Abdominal pain other specf st

R10.10   Upper abdominal pain, unspecified
R10.2    Pelvic and perineal pain
R10.30  Lower abdominal pain, unspecified

 

Example #2

Another practice had only a few 786.09 codes used. There are 5 new codes to replace this one. Will the report provide the pertinent information?

ICD-9 Code

ICD-10  Codes

786.09 Respiratory abnormal NEC

R06.00  Dyspnea, unspecified
R06.09  Other forms of dyspnea
R06.3    Periodic breathing
R06.83 Snoring
R06.89 Other abnormalities of breathing

 

Example #3

Almost 6% of patients seen in 2013 had headaches as a diagnosis. This may be an easy fix…

ICD-9 Code

ICD-10 Codes

784.0 Headache

G44.1  Vascular headache, not elsewhere classified
R51     Headache

 

Example #4

The nightmare! 7% of all patients seen in this practice in 2013 had a diagnosis of 729.5 pain in limb. In ICD-10 there are 30 more detailed codes that describe where the pain is located. Let’s make sure that the radiologist report is specific enough!

ICD-9 Code

ICD-10 Codes

729.5 Pain in Limb

M79.601  Pain in right arm

M79.602  Pain in left arm

M79.603  Pain in arm, unspecified

M79.604  Pain in right leg

M79.605  Pain in left leg

M79.606  Pain in leg, unspecified

M79.609  Pain in unspecified limb

M79.621  Pain in right upper arm

M79.622  Pain in left upper arm

M79.629  Pain in unspecified upper arm

M79.631  Pain in right forearm

M79.632  Pain in left forearm

M79.639  Pain in unspecified forearm

M79.641  Pain in right hand

M79.642  Pain in left hand

M79.643  Pain in unspecified hand

M79.644  Pain in right finger(s)

M79.645  Pain in left finger(s)

M79.651  Pain in right thigh

M79.652  Pain in left thigh

M79.659  Pain in unspecified thigh

M79.661  Pain in right lower leg

M79.662  Pain in left lower leg

M79.669  Pain in unspecified lower leg

M79.671  Pain in right foot

M79.672  Pain in left foot

M79.673  Pain in unspecified foot

M79.674  Pain in right toe(s)

M79.675  Pain in left toe(s)

M79.676  Pain in unspecified toe(s)

 

Example #5

Life is not all bad! There is a one-to-one mapping for unspecific abdominal pain. What a relief that is!

ICD-9 Code

ICD-10 Codes

789.00 Abdominal pain unspecific

R10.9   Unspecified abdominal pain


Each practice should assess how this change in diagnosis coding applies to them.  Then determine what work processes should be modified to facilitate successful implementation of this new detail. Positive education and teamwork now will diminish punitive repercussions later.


ABOUT THE AUTHOR

Photo of Steven SchrieberSteve Schreiber is a Senior Management Consultant at IMAGINE Software. Schreiber has 24 years of medical practice management experience with the emphasis being in radiology. He has managed hospital-based and combined hospital/imaging center practices in highly competitive environments and has been an active member of RBMA since 2002. He is currently serving on the Board of Directors, past Parliamentarian, Vendor Relations Committee chair and as a member of various other committees. The RBMA has recognized Schreiber in the 2013 class of RBMA Fellows and has also presented Schreiber with special recognition awards in both 2005 and 2011 for his contributions to the RBMA practice management forums.

Blog - IMAGINE Management Team

medicalmoneyWhy is it that providers of healthcare services do not know what they are being paid at the time of service? Simple, because there are 3rd party payers who stand between the provider and consumer. Most of these payers are in the business of collecting premiums, investing, and withholding payments whenever possible. Perhaps the biggest issue is that even when a contractual relationship exists between the provider and 3rd party payer, there are times where the provider is not paid as expected.

The obvious reason is the denial. This is the “gotcha” where the provider is contractually obligated to follow certain procedural rules which include reasons for providing the service, obtaining approval in advance, or realizing who pays the bill first when more than one payer is available. Equally, there are after the fact denials where a service is not even covered or the contract with the patient terminated. Moreover, each payer can make up their own rules at will. The Medicare 2% sequestration reduction implemented earlier this year is a great example. Finally, should the reason for the service involve an auto or work-related accident, all bets are off.

docxraysEven when all the rules are followed, the resulting payment can be an incorrect amount. Payers have hundreds of payment contracts and fee schedules. It is quite easy for a 3rd party claims processer to make an incorrect payment. How does this happen? Sometimes it is based on selecting a provider’s prior practice contract rate. Other times it can be based on selecting the “rack rate”.  Perhaps it was due to selecting an expired contract fee schedule with the current provider or the wrong RVU year.  Perhaps the processor selected a non-contrast CPT when a contrast-enhanced study was performed. The fact of the matter is underpayment of services happens more than we realize. And given the downward pressure of payments, we all need to make sure that we are being paid appropriately!

Today’s practice management billing software is capable of letting management know when underpayments occur due to payers making erroneous payments. It is important that practices work with the software to load fee schedules for all 3rdneedtoknow party contract plans. It is important that practice personnel include the allowable rate when manually processing claims along with the payment and required co-payment.  It is then possible for practice management to periodically check to make sure that 3rd party payers have paid the correct rate. Those seemingly small underpayments compared to the actual contract rate can add up quickly. It is the old adage of watching the pennies and the dollars will take care of themselves. Regardless of being an IMAGINE client or not, I would urge all practices to check your payments against your contract rates. If you are an IMAGINE client, please feel free to contact your CRM to make sure that you have taken all the necessary steps as part of optimizing of your revenue cycle management program.
 


ABOUT THE AUTHOR

Photo of Steven SchrieberSteve Schreiber is a Senior Management Consultant at IMAGINE Software. Schreiber has 24 years of medical practice management experience with the emphasis being in radiology. He has managed hospital-based and combined hospital/imaging center practices in highly competitive environments and has been an active member of RBMA since 2002. He is currently serving on the Board of Directors, past Parliamentarian, Vendor Relations Committee chair and as a member of various other committees. The RBMA has recognized Schreiber in the 2013 class of RBMA Fellows and has also presented Schreiber with special recognition awards in both 2005 and 2011 for his contributions to the RBMA practice management forums.

Blog - IMAGINE Management Team

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