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With radiology claims under tighter OIG scrutiny, compliance is always your safest bet.

Radiology has faced compliance issues for years, according to Marianne Durling, MHA, RHIA, CPC, CCS, CDIP, CPCO, CIC, CDEI, 星空入口Approved Instructor, in her HEALTHCON 2024 session 鈥淒on鈥檛 Gamble With Your Facility鈥檚 Radiology Revenue by Ignoring Radiology Compliance Issues.鈥�

鈥淣o matter what you did, you got paid for it: It was not a big deal,鈥� Durling said. Auditors didn鈥檛 really look at radiology, 鈥渂ut that鈥檚 all changed,鈥� she continued. Auditors are now looking at both lab and radiology services. What used to be considered safe, comfortable income for radiology facilities and providers is now up for review.

Avoid gambling with your revenue stream and putting your practice at risk by reviewing recent government rulings, common compliance issues, and areas of risk to watch out for in radiology.

Review Recent OIG Findings

The Office of Inspector General (OIG) has been clamping down on radiology fraud and abuse. Recent million-dollar investigations and settlements include:

• $85.5 million settlement: Cardiac Imaging, Inc. (CII) agreed to pay $75 million, and its CEO Sam Kancherlapalli agreed to $10,480,000, for allegedly paying referring cardiologists excessively to supervise PET scans between March 1, 2014, and May 31, 2023. Fees were paid for time when cardiologists weren鈥檛 present and services weren鈥檛 provided. The settlement resolved claims brought under the whistleblower provisions of the False Claims Act, where CII and Kancherlapalli knowingly caused false or fraudulent claims submission to federal healthcare programs, violating the anti-kickback statute and the Stark Law.
• $3.1 million settlement: paid this sum to the OIG after the United States-based radiologists admitted to not conducting meaningful and adequate review of radiology scan draft interpretations prepared by India-based contractors who were not licensed. They also allegedly submitted claims for reimbursement to federal healthcare programs in which the radiologist who reviewed and interpreted the imaging was not the person listed on the claim.
• $6.5 million lawsuit: Between 2016 and 2019, Pennsylvania interventional radiologist James McGuckin, MD, and his practice allegedly submitted to Medicare for unnecessary vascular procedures, including angioplasty, atherectomy, and placement of stents. McGuckin is a repeat offender, having been sanctioned in several states in previous years for similar wrongdoing.

Adhere to Proper Billing Requirements

To be compliant with radiology billing requirements, you need:

• A valid order,
• Supervision and interpretation,
• A written report, and
• Images stored permanently in the patient record.

A valid order means the provider is credentialed, is allowed to place the order, and is properly entered and recognized in your billing system. To bill normal radiology services, all these things need to be present.

According to Durling, 鈥淲hen radiology has to be part of another service line鈥檚 procedure, we鈥檝e got to really make sure we have people at the table discussing coding challenges, the billing challenges, the regulatory requirements so that they鈥檙e met.鈥� For example, there鈥檚 a good chance that somebody in neurosurgery, pediatrics, or gastroenterology has no clue about what the radiology components are; they just know they are supposed to do radiology as part of the procedure.

When billing radiology services, you need to know modifier use when only part of a service is rendered, bundling rules, and what is included in the global package. Consider the following modifiers for proper billing:

• Modifier 26 (Professional component): Append modifier 26 if you are just billing for the professional reading and interpretation.
• Modifier TC (Technical component 鈥�): Append modifier TC if you are the facility or location that鈥檚 expensing the cost for the equipment and staff to perform the radiology service.
• Global package: If you are addressing all components together, and it鈥檚 all being paid from one entity, bill the procedure code without a modifier.

Check the National Correct Coding Initiative (NCCI) Procedure-to-Procedure Edits, Medically Unlikely Edits (MUEs), and Add-on Code Edits to help ensure you are reporting correct coding combinations for reimbursement. 鈥淢ake sure you鈥檙e aware of the edits and you understand the bundling rules,鈥� Durling said, 鈥渂ecause 鈥� a lot of services are bundled into another service.鈥�

It鈥檚 not always easy to meet all four components of billing requirements. For example, there has been a trend in point-of-care ultrasound (POCUS) in some facilities. The downside to them is that 鈥渨ith point-of-care ultrasounds, you don鈥檛 necessarily get supervision and interpretation, and a lot of times images are not permanently stored somewhere,鈥� Durling said. With a lot of new radiology services (i.e., POCUS), all billing requirements are forgotten, so you can鈥檛 bill for them.

Understand Precertification and Preauthorization

More preauthorization (pre-auth) requirements have been added for radiology services, not just for CTs and MRIs. Durling said, 鈥淲e are seeing additional services that never required pre-auths needing pre-auths all of a sudden.鈥�

Many providers were setting up acceptable use criteria (AUC) prior to COVID-19. 鈥淭hen COVID hit,鈥� said Durling, 鈥渁nd kind of threw it under the bus for a while.鈥� She ensures that AUC will make a comeback because it ensures providers are ordering the appropriate radiology services.

Many high-volume radiology facilities pay radiologists to do 鈥減rotocoling鈥� the day before, which is where they look at all the orders coming up for the next day or two and ask themselves, 鈥淒oes this study make sense to address the clinical indication/question?鈥� They will then spend time changing and protocoling orders. AUC can help providers who don鈥檛 do a lot of necessary radiology orders, such as family medicine and internal medicine doctors. 鈥淎UC defines what tests are needed, what鈥檚 appropriate, and whether something else needs to be ordered prior to the imaging,鈥� according to Durling.

Be cautious about using AUCs and product updates, however. You may have everything set up and then an update will come out that is not compliant. The AUC product contractors may try to push the updates on you even though they aren鈥檛 compliant and refuse to make changes to remedy the compliance issues. This puts your claims and healthcare organization at risk. 鈥淧lease make sure that even after everything鈥檚 signed and done that somebody鈥檚 looking at those updates to make sure they are still compliant,鈥� Durling warned.

Example: Durling had a physician group call and say they have been doing facet joint injections for the same group of patients for 10 to 20 years, and now the Centers for Medicare & Medicaid Services (CMS) is making them jump through hoops to get them paid, to the point that the physician group wants to make the patients self-pay out-of-pocket. According to Durling, the problem is the new rules are for new patients, and the new requirements don鈥檛 address patients who have been getting injections for years. 鈥淢y suggestion was we dig back through medical records and find all the original diagnostic things that were done to qualify them the first go-round,鈥� Durling said. 鈥淭here were paper records somewhere, and that鈥檚 the best you can do for these patients to ensure the facet joint injections are still covered.鈥�

Be proactive when you know there are payment or policy changes coming so you don鈥檛 have to find out the hard way 鈥� months after the fact 鈥� that you aren鈥檛 meeting pre-auth requirements. Talk with your payer relations group to see if new policy changes affect your specific contracts with commercial payers.

Learn About Other Risks and Audit Areas

There are other areas that are risky in terms of maintaining compliance or that the OIG is paying extra attention to, as well. They include:

• Limited vs. complete: CPT^庐 codes for ultrasound make the distinction between a 鈥渓imited鈥� and 鈥渃omplete鈥� exam. When you report a complete exam, be sure all components are imaged and documented.
• Intensity-modulated radiation therapy (IMRT): Recovery audit contractors (RACs) are auditing diagnostic and therapeutic radiology, and the most recent focus has been on IMRT.
• Duplex scans: Targeted probe-and-educate auditors have been reviewing duplex scans.
• Independent diagnostic testing facilities (IDTF): To be considered 鈥渋ndependent,鈥� Medicare coverage and payment policy rules for IDTFs 鈥渉ave a ton of hoops you have to jump through to qualify,鈥� said Durling. You can only do diagnostic procedures, and it鈥檚 very limiting.
• Nuclear medicine: Auditors are looking at billing compliance of ventilation-perfusion (VQ) scans, brain scans, and full body scans (similar to PET scans).
• New technologies: These can include approved and non-approved devices and procedures that are not part of an approved trial or study. For example, if you are using the new CT-enhanced digital mammography and magnetic resonance-guided hi-intensity focused ultrasound (MRgHIFU) for essential tremor treatment, be sure you know the requirements, who and what you can bill, bundling rules, modifiers, etc.

Good resources to help bolster radiology claims compliance include professional medical societies for diagnostic radiology, such as the American Society of Radiology and American Society of Nuclear Cardiology.

Note: This article was originally published in the October 2024 issue of 星空入口the Magazine.

Michelle A. Dick, BS, Development Editor, AAPC