Coding and Reimbursement Toolkit

What do I need know?

SIR's Coding and Reimbursement toolkit curates an array of society and external resources designed to help you better understand and meet the AMA CPT codebook rules and guidelines.

Providers (not coders) are ultimately responsible for using the CPT coding system correctly. New coding changes for interventional radiology procedures occur annually, and can be complex. These changes affect reimbursement, and improper coding may result in penalties.

The Healthcare Common Procedure Coding System (HCPCS) is divided into two subsystems, Level I and Level II. Level I is comprised of Current Procedural Terminology (CPT), a coding system that identifies medical services and procedures furnished by physicians and other health care providers. Health care providers use CPT to bill public or private health insurance programs. The American Medical Association (AMA) maintains CPT, and makes decisions regarding addition, deletion or revision of CPT codes. CPT codes are updated and published annually. The existence of a CPT code does not determine coverage or non-coverage for a service or procedure.

HCPCS Level II is a coding system that identifies products, supplies and services that are not CPT code set jurisdiction, such as medical equipment and devices. Suppliers use HCPCS Level II to bill public or private health insurance programs. CMS maintains most HCPCS Level II codes, and makes decisions regarding addition, deletion or revision of most HCPCS Level II codes. Permanent HCPCS Level II codes are updated annually and temporary codes quarterly. Common HCPCS codes include the G codes and S codes. The existence of a HCPCS Level II code does not determine coverage or non-coverage for an item or service.

The International Classification of Diseases (ICD) is a coding system that identifies diseases and other health problems. It has clinical, epidemiological, and health management applications. For example health care providers use ICD to classify diseases on health records, and ICD is used for reimbursement. The most current version is the 10^th revision (ICD-10), which was adopted in the United States on October 1, 2015. ICD is currently under revision, and the release date for ICD-11 is 2018.

Coding Questions?

The first step to answering a coding question is to consult the latest Interventional Radiology Coding Update. The annual Coding Update and its accompanying charge sheets are complimentary and available only to SIR members. The files are available within SIR member's online account within the Digital Content section of their member profile.

If you are not able to locate an answer to your question from the Coding Update, the next step is to electronically communicate it to the SIR staff. This ensures that the details of your coding question do not get lost in translation from a phone message. Ask questions using this form or via email directly to Debbie Ramsburg, SIR health policy and quality coordinator.

SIR's Health Policy and Economics division will make a determination about questions that can be answered by SIR staff or sent on to the Coding Education and Application Workgroup of the Economics Committee, where expert volunteer physicians review each question and develop a response. Please allow one to two weeks for a response. Once our volunteers provide their input, a consensus response is generated and sent back via email to the requester.

While the SIR Coding Education and Application Workgroup consists of experts in coding nomenclature, the SIR assumes no liability, legal, financial, or otherwise, for physicians or other entities who utilize this information in a manner inconsistent with the coverage and payment policies of any payors or Medicare contractors to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.

Multiple procedure payment reduction (MPPR) rate set

Radiologists will only see a 5 percent reduction in payment in 2017 instead of a 25 percent reduction, under the Centers for Medicare and Medicaid Services (CMS) proposed multiple procedure payment reduction (MPPR) rate, which is effective Jan. 1, 2017. In September, SIR submitted comments on the CMS proposed rule implementing this rate. United Healthcare will adopt the Medicare MPPR for the professional component of advanced imaging services covered by its commercial health insurance plans.

ICD-10 coding alert: Reduce use of unspecified codes

CMS will end the one year grace period and stop allowing the use of unspecified diagnosis codes on Oct 1. Data shows that across the specialty of radiology, usage of unspecified codes are at an increase of approximately 10 percent from ICD-9-CM. CMS provides guidance on how your practice can reduce the usage of unspecified codes and increase revenue in its publication "Expiration of Medicare flexibilities."

SIR believes that clinical practice is important. Learn how new consults for IR, pre-and post-procedural care and inpatient rounding revenues help your practice in this presentation.

Disclaimer:

The Society of Interventional Radiology (SIR) is providing this billing and coding guidance for educational and information purposes only. It is not intended to provide legal, medical, or any other kind of advice. This guidance is meant to be an adjunct to the American Medical Associations (AMA) Current Procedural Terminology (CPT® c. 2017). IIt is not comprehensive and does not replace CPT. Our intent is to assist physicians, business managers, and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service.

Every reasonable effort has been made to ensure the accuracy of this guidance; but SIR and its employees, agents, officers, and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guidance will prevent differences of opinion or disputes with payers. This information is provided "as is" without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this information. The ultimate responsibility for correct use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize this information in a manner inconsistent with the coverage and payment policies of any payors, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.

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