Offensive strategy may be mammographers’ best bet in reimbursement war

NEW ORLEANS - High-quality breast imaging services, rigorous quality assurance, and a healthy bottom line aren't mutually exclusive, says Dr. Michael Livner. As long as mammographers remember that trying to do all three amounts to a declaration of war.

"We are involved in a true war to survive. Breast imaging has become a great paradox. Our costs continue to rise. Mammography has become more sophisticated. We are under the scrutinizing eye of the public and the private sectors," Livner said at the Breast Imaging Conference on October 6. The conference is sponsored by the Medical College of Wisconsin and Instrumentarium Imaging, both of Milwaukee.

Linver, director of mammography at X-Ray Associates of New Mexico in Albuquerque, presented a strategy for facing the "enemy" -- in this case, Medicare, HMOs, and other payors -- that doesn’t sacrifice good medicine and can result in a healthy bottom line.

"The key to success is cracking the enemy code, and making sure that you are reimbursed for your services," Linver said.

The first weapon in the mammographer's arsenal is a meticulous adherence to the various reimbursement codes. These include the International Classification of Disease -- Ninth Revision (ICD-9) from the World Health Organization, the American Medical Association’s Current Procedural Terminology (CPT) system, and HCPCS, the Common Procedure Coding System administered by the Health Care Financing Administration. Payment is based on coding, so it behooves a practice to get the codes correct from the start, Linver said.

"The game plan for most reimbursement is to delay and deny payment," Linver said. "Your goal, then, is to prevent the denial before it takes place."

Here are a few front-line strategies:

  • Obtain a signed referral from the primary care physician (PCP).

  • Update the "cheat sheet," or short list of CPT codes, on a regular basis. Follow the Local Medicare Review Policy for any changes, because payment schedules can differ from region to region. For example, in the Northeast, a radiologist can be reimbursed for a diagnostic mammogram to pinpoint malignant melanoma. A radiologist in the Oklahoma-New Mexico area cannot do the same, but he could bill for plastic surgery after care, Linver said.

  • Use multiple ICD-9 codes when applicable, such as when a core biopsy or other inverventional exam is done. "Remember that you can’t get paid for the exam if you don’t bill. If you don’t bill, the payor isn’t going to say to you ‘Why didn’t you bill for this?’" he said.

  • Correctly identify whether the exam is diagnostic or screening, indicate the views performed, and list the clinical history.

  • Don’t upcode inappropriately. Some of the compliance issues that keep the Office of the Inspector General in business include billing for services not rendered, unnecessary services, and duplicate billing, Linver said.

  • Don’t surrender to the strong-arm of Medicare by providing mediocre care. "Medicare rewards mediocrity. It doesn’t matter how good a job you do, you still get paid $67 for the [screening] exam," Linver said. "We are faced with a great dilemma, so there is a temptation to compromise on quality. But mammography only works if it is of high quality."

  • Don’t re-bill patients. If it happens too often, payors grow suspicious and will set up an "adverse profile" for the practice.

  • Don’t send in a report and a bill with two different sets of information. If the referring physician has ordered a screening exam, don’t conduct and bill for a diagnostic one, even if it seems more appropriate for addressing a patient’s health issues. "Then you are potentially at risk for fraud. Because of the nature of the system, your performance must mirror what the [primary care] provider ordered," he said.

Next page: Make referring physicians your allies

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