Can we perform multiple CT scan on different area on same day? Would Medicare pay?

Computerized Axial Tomography (CT) Procedures


A/B MACs (B) do not reduce or deny payment for medically necessary multiple CT scans of different areas of the body that are performed on the same day.

The TC RVUs for CT procedures that specify “with contrast” include payment for high osmolar contrast media. When separate payment is made for low osmolar contrast media under the conditions , reduce payment for the contrast media as set forth in §30.1.2.


30.1 - Low Osmolar Contrast Media (LOCM) (HCPCS Codes Q9945-Q9951)

HCPCS codes A4644-A4646 have been replaced with Q9945-Q0051.


 Payment Criteria


A/B MACs (B) make separate payments for LOCM (HCPCS codes Q9945-Q9951) in the case of all medically necessary intrathecal radiologic procedures furnished to nonhospital patients. Effective January 1, 2005 in the case of intraarterial and intravenous radiologic procedures, the five restrictive criteria (a history of previous adverse reaction to contrast material, with the exception of a sensation of heat, flushing, or a single episode of nausea or vomiting; a history of asthma or allergy; significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension; generalized severe debilitation; or sickle cell disease) for the payment of LOCM are eliminated.

Payment for Interpretation of Diagnostic Tests Furnished to Emergency Room Patients

 As a condition of fee schedule payment, services are required to contribute directly to the diagnosis or treatment of an individual beneficiary.5 When Medicare Administrative Contractors (MAC) receive a single claim for interpretation and report, “they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure …”60

However, when a MAC receive[s] multiple claims for the same interpretation “[MACs must] pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient.” The Medicare Claims Processing Manual does not require contractors to confirm that interpretations were performed at the same time that the patient was in the emergency department or that the interpretation contributed to the diagnosis and treatment of the individual beneficiary when a single claim is submitted.

7 The Medicare Claims Processing Manual goes on to state that MACs must “pay for the interpretation billed by the . . . radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary.” Any other reinterpretation of the original interpretation (e.g., one that was performed after the beneficiary has left the emergency department) should be treated and reimbursed through the diagnosis-related group as part of the hospital’s quality assurance program.8


Medicare payments for diagnostic radiology services in hospital outpatient emergency departments have two components: a technical component,9 paid by Part A; and a professional component, paid by Part B. This report addresses only the professional component, which includes payments for physicians’ interpretations of images and reports on the clinical findings for inclusion in beneficiaries’ hospital-maintained medical records.10 Payments for the professional component are sent to interpreting physicians (i.e., emergency room physicians or radiologists).11


After diagnostic radiology services are ordered by emergency department physicians, they can:

• review diagnostic radiology images as part of evaluation and management (E/M) services for beneficiaries,12

• perform interpretation and reports of diagnostic radiology services, and/or

• consult with radiologists for their interpretation and reports on the findings for diagnostic radiology services.13

Claims submitted for interpretations without complete written reports do not meet the conditions for payment.


Both emergency department physicians and radiologists may be paid for their interpretation and reports for CTs, MRIs, or x-rays.
14 Medicare generally pays for only one interpretation and report for each diagnostic radiology service furnished to an emergency department patient.15

PRIOR AUTHORIZATION FOR OUTPATIENT HIGH-TECH IMAGING SERVICES

Tufts Health Plan requires providers to obtain authorization prior to requesting high-tech imaging services in an outpatient setting. Depending on the member’s product, providers must call either National Imaging Associates (NIA) or Cigna.

The following services require prior authorization:
*CT/CTA
**MRI/MRA
**PET Scan
**Nuclear Cardiology

It is the ordering provider’s responsibility to obtain prior authorization before scheduling appointments for Tufts Health Plan members. Rendering providers will need to ensure that all tests for Tufts Health Plan members have the required authorization number before the service is performed. Both professional and technical claims for which there is no authorization number will be denied and the member may not be billed for the service associated with the denied claim.

Note: Diagnostic imaging services performed in the emergency room, observation, and inpatient settings do not require prior authorization. Emergency CT/CTA, MRI/MRA, PET scan or Nuclear Cardiology procedures rendered at a location site other than a hospital emergency room require notification to NIA within two business days of the service.

At this time, the prior authorization program for high-tech imaging services does not apply to CareLink, Uniformed Services Family Health Plan, Tufts Medicare Preferred HMO, Tufts Health Plan Senior Care Options and MCP members.

CT Scan and MRI Scan Interpretation report Erroneous claims and how to avoid it.

BACKGROUND

The Social Security Act and Centers for Medicare & Medicaid Services (CMS) regulations govern Medicare payments for all radiology services and require that services be medically necessary, have documentation to support the claims, and be ordered by physicians.

We used the 2008 National Claims History File to identify 9.6 million Medicare claims ($215 million) for interpretation and reports of diagnostic radiology services for beneficiaries in hospital outpatient emergency departments. Our review consisted of two simple random samples of claims: a sample of 220 CT and MRI claims and a sample of 220 x-ray claims. We used a document review instrument to review all medical record documentation requested from facilities for each sampled claim. We considered sampled claims erroneous if (1) documentation did not support that services were performed or (2) physicians’ orders were not present. We also reviewed all interpretation and reports to determine whether they were performed during beneficiaries’ diagnoses and treatments in hospital outpatient emergency departments. Finally, we reviewed interpretation and reports for all sampled claims for consistency with the American College of Radiology’s suggested documentation practice guidelines.


FINDINGS
In 2008, Medicare claims for interpretation and reports of 19 percent of CTs and MRIs and 14 percent of x-rays in hospital outpatient emergency departments were erroneous because of insufficient documentation. Of the nearly 3 million claims allowed for interpretation and reports of CT and MRI services in hospital outpatient emergency departments in 2008, Medicare erroneously allowed 19 percent, amounting to nearly $29 million. Of the nearly 6.6 million claims allowed for interpretation and reports of x-ray services in hospital outpatient emergency departments in 2008, Medicare erroneously allowed 14 percent, amounting to nearly $9 million. Physicians’ orders were not present in medical record documentation for 12 percent of CT and MRI interpretation and report claims, amounting to nearly $18 million. Physicians’ orders were not present in medical record documentation for 9 percent of x-ray interpretation and report claims, amounting to $5 million. Documentation was not provided to support that interpretation and reports had been performed for 12 percent of CT and MRI claims, amounting to nearly $19 million, and 8 percent of x-ray claims, amounting to $5 million.


In 2008, Medicare paid for interpretation and reports performed for 16 percent of x-rays and 12 percent of CTs and MRIs after beneficiaries left hospital outpatient emergency departments; CMS offers inconsistent payment guidance on the timing for interpretation. CMS’s guidance to contractors states that contractors are to pay only for the interpretation performed “at the same time” as the diagnosis and treatment of the beneficiary in the emergency room if contractors receive multiple claims from, for example, the emergency room physician and the radiologist. However, contractors are not required to confirm that the interpretation was performed while the beneficiary was in the emergency department if only one claim is received. Medicare allowed more than $10 million (16 percent of claims) for interpretation and reports of x-rays that were performed after beneficiaries left hospital outpatient emergency departments and, based on OIG’s prior work in this area, may not have contributed to beneficiaries’ diagnoses and treatments. Of the $10 million, $7.5 million was for claims that had physicians’ orders and documentation to show that interpretation and reports had been performed. In addition, Medicare allowed $19 million for interpretation and reports of CTs and MRIs that were performed after beneficiaries left hospital outpatient emergency departments. Of the $19 million, $5.4 million was for claims that had physicians’ orders and documentation to show that interpretation and reports were performed.

Interpretation and reports for 71 percent of x-rays and 69 percent of CTs and MRIs in hospital outpatient emergency departments did not follow one or more suggested documentation practice guidelines promoted by the American College of Radiology. Seventy-one percent of interpretation and reports for x-rays did not follow one or more suggested practice guidelines. Sixty-nine percent of interpretation and reports for CTs and MRIs did not follow one or more suggested practice guidelines. Documentation standards for interpretation and reports are essential for determining whether diagnostic radiology services contribute to beneficiaries’ diagnoses and treatments.


 RECOMMENDATIONS

We recommend that CMS:

Educate providers on the requirement to maintain documentation on submitted claims. Adopt a uniform policy for single and multiple claims for interpretation and reports of diagnostic radiology services to require that claimed services be contemporaneous or identify circumstances in which noncontemporaneous interpretations may contribute to the diagnosis and treatment of beneficiaries in hospital outpatient emergency departments. Take appropriate action on the erroneously allowed claims identified in our sample.


AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE

In its written comments on the report, CMS concurred with the first and third recommendations. CMS did not concur with the second recommendation. In response to the first recommendation, CMS indicated that it will issue an educational article to the provider community to emphasize that documentation requirements will be enforced. In response to the third recommendation, CMS indicated that upon receipt of the files from the Office of Inspector General, it will take appropriate action. CMS will instruct the Medicare Administrative Contractors to consider this issue when prioritizing their medical review strategies or other interventions.


In response to the second recommendation, CMS indicated that it does not believe that a single billed interpretation must, in all cases, be contemporaneous with the beneficiary’s diagnosis and treatment to contribute to that diagnosis and treatment. A uniform policy requiring that interpretation and reports be contemporaneous with, or, if not contemporaneous, demonstrably contribute to the beneficiary’s diagnosis and treatment could reduce unexplained complexity in what is already a complicated billing system for medical diagnostics. We have revised the language of the second recommendation to clarify what we are recommending.

Computed tomography (CT) imaging

What is CT Imaging?

Computed tomography (CT) imaging, also referred to as a computed axial tomography (CAT) scan, involves the use of rotating x-ray equipment, combined with a digital computer, to obtain images of the body. Using CT imaging, cross sectional images of body organs and tissues can be produced. Though there are many other imaging techniques, CT imaging has the unique ability to offer clear images of different types of tissue. CT imaging can provide views of soft tissue, bone, muscle, and blood vessels, without sacrificing clarity. Other imaging techniques are much more limited in the types of images they can provide.

To understand the difference between CT imaging and other techniques, consider an x-ray of the head. Using basic x-ray techniques, the bone structures of the skull can be viewed. With magnetic resonance imaging (MRI), blood vessels and soft tissue can be viewed, but clear, detailed images of bony structures cannot be obtained. On the other hand, x-ray angiography can provide a look at the blood vessels of the head, but not soft tissue. CT imaging of the head can provide clear images not only of soft tissue, but also of bones and blood vessels.

CT imaging is commonly used for diagnostic purposes. In fact, it is a chief imaging method used in diagnosing a variety of cancers, including those affecting the lungs, pancreas, and liver. Using CT imaging, not only can physicians confirm that tumors exist, but they can also pinpoint their locations, accurately measure the size of tumors, and determine whether or not they’ve spread to neighboring tissues.

In addition to the diagnosis of certain cancers, CT imaging is used for planning and administering radiation cancer treatments, as well as for planning certain types of surgeries. It is useful for guiding biopsies and a range of other procedures categorized as minimally invasive. Thanks to its ability to provide clear images of bone, muscle, and blood vessels, CT imaging is a valuable tool for the diagnosis and treatment of musculoskeletal disorders and injuries. It is often used to measure bone mineral density and to detect injuries to internal organs. CT imaging is even used for the diagnosis and treatment of certain vascular diseases that, undetected and untreated, have the potential to cause renal failure, stroke, or death.

CT imaging is pain-free. Some individuals, however, may experience some discomfort because of the requirement to lie still for a period of time. The procedure is typically performed by a well-trained CT technologist.