Dial-In Instructions

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1 Dial-In Instructions Conference name: Interventional Radiology: Accurate Coding for Appropriate Reimbursement Scheduled conference date: Tuesday, March 13, 2007 Scheduled conference time: Scheduled conference duration: 1:00 p.m. 2:30 p.m. (Eastern), 12:00 p.m. 1:30 p.m. (Central), 11:00 a.m. 12:30 p.m. (Mountain), 10:00 a.m. 11:30 a.m (Pacific) 90 minutes PLEASE NOTE: If the audioconference occurs March through November, the time may reflect daylight savings. If your area does NOT observe daylight savings, times will be one hour earlier. Your registration entitles you to ONE telephone connection to the audioconference. Invite as many people as you wish to listen to the audioconference on your speakerphone. Permission is given to make copies of the written materials for anyone who is listening. In order to avoid delays in connecting to the conference, we recommend that you dial into the audioconference 15 minutes prior to the start time. Dial-in instructions 1. Dial 800/ and follow the voice prompts. 2. You will be greeted by an operator. 3. Give the operator the pass code, , and the last name of the person who registered for the audioconference. 4. The operator will verify the name of your facility. 5. You will then be placed into the conference. Technical difficulties 1. If you experience any difficulties with the dial-in process, please call the conference center reservation line at 800/ If you need technical assistance during the audio portion of the program, please press the star (*) key, followed by the 0 key, on your touch-tone phone, and an operator will assist you. If you are disconnected during the conference, dial 800/ Q&A session 1. To enter the questioning queue during the Q&A session, callers need to push the star (*) key, followed by the 1 key, on their touch-tone phones. Note: For most programs, the Q&A portion of the program generally falls after the first hour of presentation. Please do not try to enter the queue before this portion of the program. 2. If you prefer not to ask your questions on the air, you can fax your questions to 877/ or 973/ However, note that you can only fax your questions during the program. Prior to the program You can also send your questions via to wwalsh@hcpro.com. The deadline to send presubmitted questions via e- mail is 5:30 PM Eastern. Please note that it is likely that not all questions will be answered. Program evaluation survey In this materials packet on page 2, we have included a program evaluation letter that has the URL link to our program survey. We would appreciate it if you could go to the link provided and complete the survey when you return to your office. Continuing education documentation If CEs are offered with this program, a separate link containing important information will be provided along with the program materials. Please follow the instructions in the CE documentation.

2 200 Hoods Lane PO Box 1168 Marblehead MA TEL FAX URL Program Evaluation Dear Program Participant, Thank you for attending the HCPro program today. We hope you found it to be informative and helpful. To ensure a positive experience for our customers and to deliver the best possible products and services, we would like your feedback. Because your time is valuable, we have limited the evaluation to some brief questions found at the link below: We would also ask that you forward the link to others in your facility who attended the program for their input as well. To ensure that your completed form receives our attention, please return to us within six days from the date of this program. If you enjoyed this program, you may purchase a tape or CD at the special attendee price of just $70. Simply call our customer service team at 800/ , and mention your source code: SURVEYAD. Keep the tape or CD handy, and listen again at your convenience whenever you or your staff might benefit from a refresher, or when your new employees are ready for training. We appreciate your time and suggestions. We hope that you will continue to rely on HCPro programs as an important resource for pertinent and timely information. Sincerely, Leokadia Marchwinski Director of Multimedia Production HCPro, Inc.

3 Interventional Radiology: Accurate Coding for Appropriate Reimbursement A 90-minute interactive audioconference Tuesday, March 13, :00 p.m. 2:30 p.m. (Eastern) 12:00 p.m. 1:30 p.m. (Central) 11:00 a.m. 12:30 p.m. (Mountain) 10:00 a.m. 11:30 a.m. (Pacific)

4 In our materials, we strive to provide our audience with useful and timely information. The live audioconference will follow the enclosed agenda. Occasionally, our speakers will refer to the enclosed materials. We have noticed that non-hcpro audioconference materials often follow the speakers presentations bullet-bybullet and page-by-page. However, because our presentations are less rigid and rely more on speaker interaction, we do not include each speaker s entire presentation. The enclosed materials contain helpful forms, crosswalks, policies, charts, and graphs. We hope that you will find this information useful in the future. HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. ii Interventional Radiology: Accurate Coding for Appropriate Reimbursement

5 The Interventional Radiology: Accurate Coding for Appropriate Reimbursement audioconference materials package is published by HCPro, Inc., 200 Hoods Lane, P.O. Box 1168, Marblehead, MA Copyright 2007, HCPro, Inc. Attendance at the audioconference is restricted to employees, consultants, and members of the medical staff of the Licensee. The audioconference materials are intended solely for use in conjunction with the associated HCPro audioconference. The Licensee may make copies of these materials for internal use by attendees of the audioconference only. All such copies must bear the following legend: Dissemination of any information in these materials or the audioconference to any party other than the Licensee or its employees is strictly prohibited. Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. For more information, please contact: HCPro, Inc. 200 Hoods Lane P.O. Box 1168 Marblehead, MA Phone: 800/ Fax: 781/ Web site: Interventional Radiology: Accurate Coding for Appropriate Reimbursement iii

6 200 Hoods Lane P.O. Box 1168 Marblehead, MA Tel: 800/ Fax: 800/ Dear Colleague, Thank you for participating in our Interventional Radiology: Accurate Coding for Appropriate Reimbursement audioconference with Jim Collins, CPC, CHCC, ACS-CA, and Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI, moderated by Brian Murphy, CPC-A. We are excited about the opportunity to interact with you directly and encourage you to ask our experts your questions during the audioconference. If you would like to submit a question before the audioconference, please send it to wwalsh@hcpro.com and provide the program date in the subject line. We cannot guarantee that your question will be answered during the program, but we will do our best to take a good cross section of questions. If at any time you have comments, suggestions, or ideas about how we can improve our audioconference, or if you have any questions about the audio-conference itself, please do not hesitate to contact me. And if you would like any additional information about our other products and services, please contact our Customer Service Department at 800/ We have enclosed an evaluation along with the audioconference materials. After the audioconference, please take a minute to complete the evaluation to let us know what you think. We value your opinion. Thanks again for working with us. Best regards, Wendy Walsh Associate Producer Fax: 781/ wwalsh@hcpro.com iv Interventional Radiology: Accurate Coding for Appropriate Reimbursement

7 Contents Agenda vi Speaker profiles vii Exhibit A Presentation by Jim Collins, CPC, CHCC, ACS-CA Exhibit B Presentation by Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI Exhibit C A set of anatomical drawings Exhibit D Billing guides for arterial placement and sequential interventions Exhibit E Coding and audit tool for interventional radiology procedures Exhibit F Pair of recent articles from HCPro s JustCoding.com Exhibit G List of useful industry acronyms Exhibit H Answers to case studies Resources Interventional Radiology: Accurate Coding for Appropriate Reimbursement v

8 Agenda I. Guidelines for interventional radiology II. III. IV. New code for 2007: Uterine fibroid embolization Billing for different components of diagnostic studies, including case studies A. Review of interventional radiology anatomy and diagrams B. Catheter position placements/imaging guidelines C. Proper coding of diagnostic studies D. Procedural coding, including: i. Angioplasties ii. Atherectomies iii. Stent insertions iv. Embolizations v. Other problematic procedures Correct coding initiative (CCI) edits, including the proper and improper applications of modifiers -59, -LT, and -RT A. Physician billing B. Facility billing V. Live Q&A vi Interventional Radiology: Accurate Coding for Appropriate Reimbursement

9 Speaker profiles Jim Collins, CPC, CHCC, ACS-CA Jim Collins is president of The Cardiology Coalition. He directs the firm s compliance and revenue enhancement services, writes the highly acclaimed Cardiology Coalition Member Newsletter, and develops each of the organization s online coder proficiency tests. He has over 14 years of experience working closely with physicians to achieve optimum profitability and regulatory compliance. He limits his practice to cardiology and is a nationally recognized expert in each of the cardiology sub-specialties. Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI Yvonne Hoiland is an instructor and senior consultant for Coding Continuum, Inc., in Tucson, AZ, where she conducts audits and operational assessments; provides education to coders, clinicians, and ancillary personnel; and works on litigation matters on behalf of both plaintiffs and defendants. Previously, she was the quality improvement coordinator for a 365-bed university-affiliated teaching facility with hospital-based outpatient clinics. She supervised a staff of 17 inpatient and outpatient coders and implemented a point-of-service/product line coding model in high revenue-generating areas, including the ED, interventional radiology, cardiac catheterization, electrophysiology lab, and endoscopy lab. She is a nationally recognized expert in the area of interventional coding, providing coding expertise at local, state, and national conferences, including AHIMA and AAPC. Interventional Radiology: Accurate Coding for Appropriate Reimbursement vii

10 Exhibit A Presentation by Jim Collins, CPC, CHCC, ACS-CA

11 EXHIBIT A Peripheral Vascular Catheterization and Diagnostic Angiography Jim Collins, CPC, CHCC, ACS-CA The Cardiology Coalition Peripheral Vascular Procedures 2 2 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

12 EXHIBIT A Component Coding 3 4 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 3

13 EXHIBIT A Cath Placement Non-selective: Movement towards or into the aorta from any access point. the access site and the aorta. selective Interventional Radiology: Accurate Coding for Appropriate Reimbursement

14 EXHIBIT A Sample & The Cardiology Coalition, All Rights Reserved 7 Selective Cath Placement 8 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 5

15 EXHIBIT A & The Cardiology Coalition, All Rights Reserved 9 ABOVE THE DIAPHRAGM first order initial second order initial third order BELOW THE DIAPHRAGM first order initial second order initial third order 10 6 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

16 EXHIBIT A Ultimate catheter placement The Cardiology Coalition, All Rights Reserved Access site lower extremity 11 Catheter placement Off the beaten path report with The Cardiology Coalition, All Rights Reserved Access site lower extremity Interventional Radiology: Accurate Coding for Appropriate Reimbursement 7

17 EXHIBIT A nd,3, *American Medical Association The Cardiology Coalition, All Rights Reserved 14 8 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

18 EXHIBIT A Cath Placement Modifiers st nd st nd *Correct Coding Initiative Edits 15 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 9

19 EXHIBIT A Key Aortic Terms A. Aortic root/ascending aorta B. Aortic arch C. Thoracic aorta/descending aorta D. Abdominal aorta E. Aorto-iliac bifurcation F. Common iliac artery G. External iliac & common femoral H. Superficial Femoral Artery (SFA) 2006 The Cardiology Coalition, All Rights Reserved 17 Aortography radiological supervision and interpretation supervision and interpretation supervision and interpretation extremity interpretation Interventional Radiology: Accurate Coding for Appropriate Reimbursement

20 EXHIBIT A Carotid Angiography selective selective selective selective Interventional Radiology: Accurate Coding for Appropriate Reimbursement 11

21 EXHIBIT A Other Specific Arteries selective ) 21 selective Interventional Radiology: Accurate Coding for Appropriate Reimbursement

22 EXHIBIT A Cath placement for first study Area studied by 1 st injection Cath placement for second study Area studied by 2 nd injection bilateral 2006 The Cardiology Coalition, All Rights Reserved 23 Both cath placements are non-selective into aorta Abdominal only bilateral LE 2006 The Cardiology Coalition, All Rights Reserved 24 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 13

23 EXHIBIT A Cath placement for study Area studied = Abdominal aorta and bilateral LE 2006 The Cardiology Coalition, All Rights Reserved 25 Still non-selective into aorta Abdominal aorta and bilateral R.O The Cardiology Coalition, All Rights Reserved Interventional Radiology: Accurate Coding for Appropriate Reimbursement

24 EXHIBIT A Cath placement for first study Area studied by 1 st injection Cath placement for second study Cath placement for third study (ext. Iliac) Area studied by 3 rd injection Area studied by 2 nd injection bilateral 2006 The Cardiology Coalition, All Rights Reserved Abdominal only Cath placement = study = bilateral LE 2006 The Cardiology Coalition, All Rights Reserved 28 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 15

25 Exhibit B Presentation by Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI

26 EXHIBIT B Interventional Radiology Interventions Yvonne Hoiland, CCS-P, CPC, CPC-H, RCC Senior Consultant Coding Continuum, Inc. New for 2007 Uterine artery embolization includes all catheterizations and intraprocedural imaging required for a UFE procedure to confirm the presence of previously known fibroids and to roadmap vascular anatomy to enable appropriate therapy Prior to 2007 change Coded for catheter placement Coded for embolization Coded for radiological guidance and supervision 2 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 17

27 EXHIBIT B Case Study #1 Radiographic Findings: With the patient in the supine position, using the normal aseptic technique and under local anesthesia, the right common femoral artery was entered with a single wall needle. Over a J guidewire, the needle was removed and replaced with a 5 French sheath with introducing dilator. Upon removing the dilator, a 4 French pigtail catheter was advanced to the level of the aortic bifurcation and a pelvic aortogram was performed. Following catheter exchange through the sheath, a 5 French Levin catheter was advanced into the distal abdominal aorta. With the aid of Glidewire, it was directed into the left common iliac artery and then into the internal iliac artery. From this point, the left uterine artery was selectively catheterized. A 3 French Mass Transit catheter over a long guidewire was advanced into the mid left uterine artery and arteriography was performed. This was followed by embolization with 500 to 700 micron Contour Embospheres, totaling 3.5 vials. Repeat arteriography was then performed. 3 Case Study #1 (cont d) Radiographic Findings (continued): The microcatheter was then withdrawn from the uterine artery and removed. The 5 French Levin catheter was also withdrawn into the common iliac artery and, over a Glidewire, advanced into the external iliac artery. A Waltman loop was then formed in the distal abdominal aorta and redirected into the right common iliac artery and eventually into the internal iliac artery. Angiogram was performed. With the aid of the Mass Transit microcatheter and its Glidewire, the right uterine artery was then selectively catheterized and arteriography was performed. Embolization with 4.5 vials of 500 to 700 micron Contour Embospheres then was performed. An additional one third of a vial of 700 to 900 micron Contour Embospheres was then utilized for additional embolization. The Waltman loop was then reduced and the catheter and microcatheters were removed Interventional Radiology: Accurate Coding for Appropriate Reimbursement

28 EXHIBIT B Case Study #1 (cont d) Through the sheath and over a guidewire, a 4 French pigtail catheter was then readvanced into the distal abdominal aorta and repeat arteriography was performed. The catheter and sheaths were then removed and adequate hemostasis was achieved. Overall, the patient tolerated the procedure well. Radiographic Report: The initial pelvic aortogram demonstrates a large dominant right uterine artery coursing over the fundus of the uterus and an enhancing and densely blushing mass, representing the dominant uterine leiomyoma. The left uterine artery is slightly smaller and fills in a more delayed fashion. Neither ovary is visualized. Selective injection with a 5 French Levin catheter into the left uterine artery demonstrates a serpiginous course of the uterine artery with multiple branches seen filling predominantly the inferolateral aspect on the left side of the uterus. 5 Case Study #1 (cont d) Following embolization, there is slow antegrade flow demonstrated in the main left uterine artery with only small collaterals noted far laterally. The right uterine artery is enlarged and demonstrates a large diameter branch coursing over the dome of the fibroid with multiple collaterals seen, especially inferomedially. These cross the midline and extend to the left. Following embolization, a small amount of antegrade, slow flow into the residual main right uterine artery is visualized, while the dominant left branch is not demonstrated. The repeat pelvic aortogram shows nonvisualization of the left uterine artery with a trace on slow antegrade flow into the right uterine artery. Impression: Bilateral uterine artery embolization for fibroids. 6 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 19

29 EXHIBIT B Transcatheter placement of an intravascular stent(s), (except coronary, carotid, and vertebral vessel), percutaneous; initial vessel each additional vessel open; initial vessel Stents each additional vessel Transcatheter introduction of intravascular stent(s), S&I, each vessel 7 Guidelines Surgical Codes Catheter placement should be coded in addition to the stent Stents should be coded for each vessel separately treated Multiple lesions in a single vessel would be coded only once Inflation of a positioning balloon during stenting should not be coded as balloon angioplasty Angioplasty performed as a method of stent deployment is not coded separately 8 20 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

30 EXHIBIT B Guidelines Radiology Codes Angiography for guidance and documentation is included in stent placement Diagnostic angiography may be coded even if performed on the same date Follow-up angiography is not coded separately 9 Case Study #2 Procedure: 1. Bilateral selective renal angiogram. 2. Stent in the left renal artery. Procedure: The patient was brought to the Special Procedures Laboratory in the postabsorptive state. Informed consent was obtained. The right groin was prepped and draped in the usual sterile fashion. Local anesthesia was achieved with infiltration of 1% Lidocaine. The right femoral artery was cannulated with an 18-gauge needle, the wire was placed and 6 French sheath was used. A 6 French internal mammary artery guiding catheter was used and bilateral selective renal angiograms were performed. These were then removed and left renal artery, diagnostic guiding type, RDC catheter was used and the left renal artery was selectively engaged. 10 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 21

31 EXHIBIT B Case Study #2 (cont d) A Supracore wire was used and the lesion was crossed. A 6.0 x 18 mm balloon expandable Racer stent was introduced. This was expanded around 8 atmospheres of pressure which is nominal. Angiography now revealed an excellent result with no residual stenosis. The hemodynamics have revealed a 30 mm gradient, which was resolved to less than 10 mm. The patient tolerated the procedure well. 11 Case Study #2 (cont d) Angiographic Findings: The right renal artery has a posterior take-off, which is widely patent with only 75% ostial stenosis is noted with above mentioned pressure gradient. Post procedure angiogram revealed an excellent result and no dissection, and good flow. The renal artery because it was very tortuous, did have some straightening. The patient tolerated the procedure well. Hemostasis was obtained and she left the catheterization laboratory in stable condition Interventional Radiology: Accurate Coding for Appropriate Reimbursement

32 EXHIBIT B Angioplasty PTA; tibioperoneal trunk or branches, each vessel renal or visceral artery aortic iliac femoralpopliteal brachiocephalic trunk or branches, each vessel venous PTA, peripheral artery, S&I each additional peripheral artery renal or other visceral artery, S&I each additional visceral artery venous, S&I 13 Guidelines Surgical Codes Code for catheter placement in addition to PTA PTA should be coded for each vessel treated Multiple lesions in a single vessel would be coded only once If angioplasty and atherectomy performed on the same vessel, both procedures should be coded if medical necessity is supported Inflation of a positioning balloon during atherectomy should not be coded as balloon angioplasty 14 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 23

33 EXHIBIT B Guidelines Radiology Codes Angiography for guidance and documentation is included in angioplasty Diagnostic angiography may be coded even if performed on the same date Follow-up angiography is not coded separately Radiological S&I codes can be used with both open and percutaneous angioplasty codes 15 Case Study #3 Procedure: After informed consent was obtained, the right groin was pepped and draped in the usual sterile fashion. Under local anesthetic and during continuous pulse oximetry monitoring and automated blood pressure cuff monitoring, the right groin was entered using a micropuncture technique. A 4 French sheath was placed in the right common femoral limb of the aortobifemoral graft. The patient was sedated with a total of 2 mg Versed and 100 mcg of Fentanyl during the procedure. A 4 French pigtail catheter was placed just above the celiac axis and a lateral aortogram was performed. The sheath was then exchanged for a 5 French sheath through which a 5 French St. Francis catheter was placed selectively in the celiac axis. A celiac axis study was performed in a left anterior oblique projection. This was followed by a celiac axis study in an anterior projection. A glide catheter was placed across the celiac axis and pressures were measured. There is a 130 mm peak systolic gradient measured with the catheter across the stenosis Interventional Radiology: Accurate Coding for Appropriate Reimbursement

34 EXHIBIT B Case Study #3 (cont d) Given the findings of the diagnostic angiogram, a decision was made to intervene with angioplasty. Using a combination of catheters and guidewires, ultimately, a 7 mm, 2 cm long balloon was placed at the celiac axis and inflated twice by hand. Moderately highgrade stenosis resolved partially. There was still a modest waste remaining. A glide catheter was then replaced in the distal common hepatic artery, contrast was injected and pressures were measured. The peak systolic pressure in the artery was now 119 mm of mercury over 60 mm of mercury with biphasic flow. Prior to the angioplasty, only monophasic flow is demonstrated. Test injection demonstrated brisk flow in the common hepatic artery improved from predilatation. Findings: There is a moderate to high grade stenosis of the stented segment of the celiac axis which is across the origin. A peak systolic gradient of approximately 130 mm of mercury was demonstrated as mentioned above. The celiac axis is patent, however, and there is flow through the gastroduodenal arcades into the occluded superior mesenteric artery. No branches of the inferior mesenteric artery were outlined on this injection. 17 Case Study #3 (cont d) recent CT scan of the abdomen and his tenuous circumstance with obvious ischemia of the bowel and portal gas. Postprocedure, hemostasis was achieved. The patient tolerated the procedure well. Conclusion: High grade stenosis of stented segment of the celiac axis with occluded superior mesenteric artery with partially successful celiac axis angioplasty reducing a 130 mm Hg peak systolic gradient to 5060mm Hg with improved flow visually. 18 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 25

35 EXHIBIT B Combos Code if: 1. One fails and the other is used to treat 2. Different treatment for different sites (okay if adjacent as long as different lesion) 3. Stent complication repaired via balloon 19 Case Study #4 Brief History: This is a 68-year old man underwent peripheral lower extremity angiogram on 02/01/07. That study revealed occluded right superficial femoral artery, 90% stenosis in the proximal SFA and 80 and 90% stenosis on other areas in the SFA. He underwent successful stenting of those lesions at that time. Angioplasty result was suboptimal. Some of the mild to moderate lesions were left alone in the SFA. The patient became symptom free on the right side; however, he continued to have significant claudication symptoms on the left lower extremity. Angiogram in February 2007 reveals 70% stenosis in the distal SFA. After detailed discussion, we decided to bring him back for angioplasty of that stenosis. Procedure: Both groins were prepped and draped in the sterile fashion. Right groin was infiltrated with 1% Lidocaine. Right femoral artery was accessed using a 6 French sheath. Following that, a LIMA catheter was tried; however, the right iliac artery appears very tortuous. Wholey wire was used to negotiate that curve. The LIMA catheter was placed at the ostium of the left common iliac artery and iliofemoral angiogram obtained. After that, a magic torque wire was tried to get down to the left SFA without success. After that, a Glidewire was successfully placed into the distal SFA. To provide a complete detailed view of the lower extremity, the LIMA catheter was brought down into the proximal part of the superficial femoral artery and superficial femoral artery angiogram with a distal run off obtained. 26 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

36 EXHIBIT B Case Study #4 (cont d) After that, a T4 was placed in the distal SFA and the LIMA catheter changed. A Glide catheter was placed, and the wire was exchanged to the magic torque wire. Over that wire, a 45 cm long arrow sheath was placed. The proximal end of the sheath was in the proximal SFA. The steel coil wire was placed back in the popliteal artery. The patient was started on intravenous Angiomax. A 5.0 x 40 mm Agiltrack balloon was placed across the mid SFA stenosis and dilated at 46 atmospheres of pressures. The same balloon was used to dilate the two long stenosis in the distal SFA, in the adductor canal. Those lesions were calcified. The fourth angioplasty result reveals dissection to all areas with a suboptimal result. Intra arterial nitroglycerin was administered. After that, the decision was made to proceed with stenting of those stenoses secondary to suboptimal results. A 6.0 x 100 mm Absolute self-expanding stent was placed across the distal SFA stenosis and deployed. Following that a 6.0 x 80 mm Absolute stent was placed across the mid/distal SFA stenosis and deployed. Both stents were postdilated using the 5.0 Agile tract balloon at 1214 atmospheres of pressure. Intracoronary nitroglycerin was administered to relieve the distal vasospasm. 21 Final angiogram revealed a very good result without any residual stenosis or dissection. Following that, the long sheath was exchanged back to the short sheath. The LIMA catheter was placed in the external iliac artery and iliofemoral angiogram with the distal runoff was obtained. The patient tolerated the procedure without complications. Findings: Left Iliofemoral Angiogram: Fifty (50%) percent focal stenosis in the external iliac artery just after the bifurcation of the common iliac artery. There was a 10 mm pressure gradient across that stenosis. Mild disease in the common femoral artery; however, that vessel is very tortuous. The mid/distal left SFA has 85% ulcerated plaque. There is a 70% long calcified stenosis in the distal SFA. There is another 70% long stenosis in the distal SFA in the adductor canal. The angiotibial runoff is very good. There is mild disease in the tibioperoneal trunk. There is moderate severe disease in the posterior tibial vessels. Right Iliofemoral Angiogram: Mild disease in the iliac and common femoral artery. The proximal SFA stent has a 40% instent restenosis. At the mid SFA stent has a 50% instent restenosis. There is an 80% focal eccentric stenosis at the distal edge of the mid SFA stent. There is another focal stenosis, which is about 70% in severity in the mid SFA. Distal SFA stent is widely patent. Case Study #4 (cont d) 22 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 27

37 EXHIBIT B Case Study #4 (cont d) Final Impression: 1. Severe stenosis in the left superficial femoral artery. 2. Suboptimal angioplasty of left superficial femoral artery stenosis. 3. Successful stenting of mid/distal left superficial femoral artery stenosis with reduction in severity from 85 0%. 4. Successful stenting of distal superficial femoral artery stenosis with reduction in severity of lesion from 70 0%. 5. Moderate instent restenosis in the proximal and mid right superficial femoral artery stents. 6. Severe stenosis in the right mid superficial femoral artery (at the prior PTA site). Recommendation: 1. Aspirin. 2. Plavix 75 mg once a day for at least one year. 3. Adjunctive medical treatment. 4. Angioplasty of right mid superficial femoral artery stenosis in one month. 23 Atherectomies Transluminal peripheral atherectomy, percutaneous; renal or other visceral artery aortic iliac femoralpopliteal brachiocephalic trunk or branches, each vessel tibioperoneal trunk and branches Transluminal atherectomy, peripheral artery, radiological supervision and interpretation each additional peripheral artery Transluminal atherectomy, renal, radiological supervision and interpretation Transluminal atherectomy, visceral, radiological supervision and interpretation each additional visceral artery Interventional Radiology: Accurate Coding for Appropriate Reimbursement

38 EXHIBIT B Guidelines Surgical Codes Catheter placement should be coded in addition to the therapies Multiple treatments should be coded for each vessel separately treated Multiple lesions in a single vessel treated by different therapies would be coded by therapy 25 Guidelines Radiology Codes Angiography for guidance and documentation is included in therapies Diagnostic angiography may be coded even if performed on the same date Follow-up angiography is not coded separately 26 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 29

39 EXHIBIT B Case Study #5 Description of Procedure: The patient was taken to the peripheral vascular lab in the fasting state after giving informed consent. A 6French sheath was introduced into the right femoral artery. A 6 French Omni Flush catheter was then introduced into the distal abdominal aorta and aortogram with runoff was performed. Preliminary findings revealed no significant disease of the distal abdominal aorta or the iliac arteries bilaterally. The left superficial femoral artery had a 75% mid stenosis which was focal. There is a patent stent in the distal left superficial femoral artery but this has approximately 50% instent restenosis. There is at least two vessel runoff to the left foot. On the right side, there is mild instent restenosis of the distal superficial femoral artery. The right popliteal artery is free of significant disease as is the right profunda. There is good one vessel runoff to the right foot through the posterior tibial artery. The anterior tibial artery is occluded proximally and the peroneal artery has sluggish flow. 27 Case Study #5 (cont d) The decision was made to proceed with atherectomy of the left superficial femoral contralateral sheath was placed across the iliac bifurcation with its distal tip in the left common femoral artery. A 300 cm wire was then advanced through a strelcut tapered glide catheter and the superficial femoral artery lesion was crossed without difficulty. The wire was placed below the knee. A L5 atherectomy Foxhollow catheter was then advanced and numerous passes at the mid and distal lesions were performed. A large amount of atheromatous material was removed from these two stenoses. Final angiography revealed less than 10% residual stenosis in the mid and distal SFA. There was no evidence of dissection or perforation, and there was good distal runoff Interventional Radiology: Accurate Coding for Appropriate Reimbursement

40 EXHIBIT B Case Study #5 (cont d) Summary of Findings: Aortogram with runoff revealed no significant disease of the distal abdominal aorta. Both iliac arteries were patent with no significant disease. The bilateral profunda femoral arteries are free of significant disease. The right superficial femoral artery has mild distal instent restenosis. The right popliteal artery is free of significant disease. Below the right knee, the right posterior tibial artery is widely patent but there is sluggish flow in the peroneal artery and the anterior tibial artery appears to be occluded proximally. On the left side, the left profunda is widely patent. The left superficial femoral artery has a focal mid 75% stenosis. There is distal 60% instent restenosis. There is at least two vessel runoff to the left foot. Successful atherectomy of the left superficial femoral artery with an L5 atherectomy catheter. There is less than 10% residual stenosis in the mid and distal SFA and there is good distal runoff. 29 Embolization Transcatheter occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, noncentral nervous system, non-head or neck Uterine fibroid embolization, percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure Transcatheter permanent occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) noncentral nervous system, head or neck (extracranial, brachiocephalic branch) Transcatheter therapy, embolization, any method, radiological supervision and interpretation Angiography through existing catheter for followup study for transcatheter therapy, embolization or infusion 30 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 31

41 EXHIBIT B Guidelines Surgical Codes Embolization may be coded only once per operative field Catheter placement should be coded in addition to the therapies 31 Guidelines Radiology Codes Angiography for guidance and documentation is included in therapies Diagnostic angiography may be coded even if performed on the same date Follow-up angiography may be coded separately Interventional Radiology: Accurate Coding for Appropriate Reimbursement

42 EXHIBIT B Case Study #6 Clinical History: The patient is a 70-year old white female with refractory bilateral epistaxis. Technique: Utilizing sterile technique and local anesthesia, direct percutaneous puncture of the right femoral artery was performed and a 6 French sheath was placed subselectively into the right femoral artery. Through this 6 French sheath a 6 French diagnostic Base catheter was utilized to subselectively catheterize the right and left common carotid arteries. Diagnostic angiography was performed in each of these 2 separate catheter positions focused on the neck and intracranial vasculature in multiple projections. No definite angiographic abnormalities are identified. Specifically no definite etiology for Following diagnostic angiography and the with Base catheter initially in the right common carotid artery a microcatheter was inserted into the patient in coaxial fashion through the indwelling Base catheter and utilized to subselectively catheterize the distal aspect of the right internal maxillary artery. 33 Case Study #6 (cont d) Diagnostic microcatheter angiography was performed to confirm catheter position and the absence of intracranial collateral vessels prior to subsequent embolization. Embolization was then performed by instilling polyvinyl alcohol or PVA particles measuring microns in diameter through the microcatheter into the right internal maxillary artery and its distal branches. Following particulate embolization, diagnostic microcatheter angiography was performed which demonstrated or suggested near occlusion of the distal branches of the right internal maxillary artery. At this point embolization of this vessel was completed by instilling a single Gelfoam pledget into the internal maxillary artery on the right again through the microcatheter. Final diagnostic microcatheter angiography suggested occlusion of the right internal maxillary artery. At this point embolization of this vessel was completed. The microcatheter was temporarily withdrawn from the patient as the Base catheter was placed into the opposite left common carotid artery. 34 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 33

43 EXHIBIT B Case Study #6 (cont d) The microcatheter was again inserted into the patient in coaxial fashion through the indwelling Base catheter and utilized to subselectively catheterize the distal aspect of the left internal maxillary artery. Again diagnostic microcatheter angiography was performed through the indwelling microcatheter to confirm catheter position and the absence of intracranial collateral vessels prior to subsequent embolization. Embolization was then performed by instilling PVA or polyvinyl alcohol particles measuring microns in diameter through the microcatheter into the left internal maxillary artery and its distal branches. Following particulate embolization, diagnostic microcatheter angiography was performed which demonstrated or suggested near occlusion of the left internal maxillary artery and its branches. Embolization of this vessel was completed by instilling a single Gelfoam pledget into the left internal maxillary artery through the microcatheter. Final diagnostic microcatheter angiography was then performed demonstrating or suggesting occlusion or near occlusion of the left internal maxillary artery and its branches. Embolization of this vessel and the procedure was then completed. 35 Case Study #6 (cont d) Diagnostic microcatheter and Base catheter were removed from the patient. The right femoral arterial sheath was also removed and pressure was held over the right groin for a period of 15 minutes to obtain adequate hemostasis. There were no apparent complications to the procedure which were identified at the time of the procedure or shortly thereafter. Conclusion: Technically successful subselective embolization of the right and left internal maxillary arteries as therapy for patient with chronic refractory epistaxis as described above Interventional Radiology: Accurate Coding for Appropriate Reimbursement

44 EXHIBIT B Modifiers Anatomical modifiers LT, RT Other modifiers Points to Remember Read the operative reports carefully Note radiology guidance and intent of guidance Note the intent of the intervention performed and any subsequent intervention Modifiers Utilize resources 38 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 35

45 Exhibit C A set of anatomical drawings Source: Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI and Coding Continuum, Inc.

46 EXHIBIT C Head and Neck Femoral Approach Current Procedural Terminology 2007 American Medical Association. All Rights Reserved CODING CONTINUUM, INC Interventional Radiology: Accurate Coding for Appropriate Reimbursement 37

47 EXHIBIT C Contralateral Lower Extremity Current Procedural Terminology 2007American Medical Association. All Rights Reserved. 2007CODING CONTINUUM, INC Interventional Radiology: Accurate Coding for Appropriate Reimbursement

48 EXHIBIT C Ipsilateral Lower Extremity. 2007CODING CONTINUUM, INC. Current Procedural Terminology 2007American Medical Association. All Rights Reserved. Interventional Radiology: Accurate Coding for Appropriate Reimbursement 39

49 EXHIBIT C Visceral Current Procedural Terminology 2007American Medical Association. All Rights Reserved. 2007CODING CONTINUUM, INC Interventional Radiology: Accurate Coding for Appropriate Reimbursement

50 Exhibit D Billing guides for arterial placement and sequential interventions Source: The Cardiology Coalition

51 EXHIBIT D February, 2007 Volume 3, Issue 2 Inside This Issue Renal Angiography Incident To Billing Renal Angiography Twenty million Americans (11% of the adult population) have chronic kidney disease. If left untreated, this disease frequently leads to kidney failure. Patients with kidney failure require dialysis or a kidney transplant in order to avoid death. Despite the availability of 3,600 dialysis facilities, 255 organ transplant facilities, and annual expenditures of approximately $18 billion dollars, over 67,000 Americans will die this year because of kidney failure. One of the front lines against the war on chronic kidney disease is in the catheterization laboratory where cardiologists spend much of their time. Prompt detection of renal artery stenosis in its early stages allows physicians to implement therapies that slow the progression of the disease and prevent patients from reaching end stage renal failure. For this reason, many cardiologists have begun imaging the renal arteries at the time of coronary procedures. Renal artery disease consists of either atherosclerotic build up in the renal arteries or the existence of fibromuscular dysplasia (FMD), a fibrous roadblock in the renal arteries that can facilitate the formation of clots. When the renal arteries are diseased the kidneys receive a reduced amount of blood flow. This deprives the kidneys of the oxygen they need to survive and decreases their ability to do their job: remove waste from the body, regulate body water, Continued on Next Page Incident To Billing for Medicare Patients The services of Non-Physician Practitioners (including physician assistants, nurse practitioners, and clinical nurse specialists) continue to be a focal point of government auditors. While the rules specific to Non-Physician Practitioner (NPP) billing have not been modified much during recent years, the government has issued several "clarifications" specific to NPP billing that illustrate its continued focus on these services. The most common way to bill for NPP services is known as "Incident To" billing. The term Incident To indicates that the services provided by the NPP are "incidental to" the physician's ongoing management of the patient. In order for NPP services to be incidental to the physician's management of the patient, the physician must perform an initial evaluation, establish a care-plan for the patient's condition, and remain actively involved in the patient's care. Because of this, the NPP can only see established patients with established problems if the services are to be billed under the incident to provision. Another requirement of the Incident To provision is that services can only be provided in the physician office when the supervising provider is physically present. The supervising provider's Continued on Pg. 4 Illustration Copyright Nucleus Medical Art, All rights reserved. CPT codes, descriptions and material only are copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. The online proficiency test has prior approval of the American Academy of Professional Coders for 2.5 continuing education units. Granting of this approval in no way constitutes endorsement by the Academy of the program, content or the program sponsor. Page 1 42 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

52 EXHIBIT D regulate blood pressure, etc. Over time, kidneys that receive reduced blood flow will shrink and die. The most definitive way to identify and assess renal artery disease is with renal angiography. When coding for renal angiography it is necessary to nail down several pieces of information. Without this data you will most likely trigger avoidable denials and attract unwanted regulatory attention. As you ll see, many of these issues overlap and influence each other: Selective vs. Non-Selective Non-selective renal angiography consists of an injection of radioopaque contrast into the abdominal aorta just above the point where the renal arteries originate. The contrast is visualized by serial radiographic imaging as it flows downstream. This is commonly referenced as a flush aortogram. While most of the contrast agent flows down the aorta, some of it trickles into the renal arteries. The radiological images created while the contrast agent is flowing through the renal arteries provide a rough indication of the extent of renal artery stenosis. Renal Arteries This image was obtained by non-selective contrast injection. The majority of contrast flows down the aorta. Selective renal angiography involves the injection of a contrast agent directly into the renal artery. Doctors frequently perform flush aortography prior to attempting selective catheterization of the renal arteries. Flush aortography images provide the doctor with a point of reference which tells him where the catheter is located in relation to the origin of the renal arteries. Using this point of reference, the doctor can shape and position the catheter so that its tip actually enters the renal artery. The contrast agent is then injected into the renal artery and radiological images of the renal artery are obtained. Selective angiography provides the doctor with more accurate and diagnostic images than non-selective angiography. This is because the concentration of the contrast agent flowing through the renal arteries is much richer if it is selectively injected into the target vessel rather than into the aorta. As previously mentioned, most of the contrast agent injected into the aorta will flow downstream in the aorta, not into the renal artery. This image was obtained by selective contrast injection. The majority of contrast flows into the renal artery. Non-selective renal angiography, performed as a stand-alone procedure, is properly reported with code (Introduction of catheter, aorta) and (Aortography, abdominal, by serialography, radiological supervision and interpretation). Selective renal angiography, performed as a stand-alone procedure, is reported with the appropriate selective catheter placement code(s) and the appropriate selective radiological supervision and interpretation code. Doctors typically position the catheter just inside the renal artery. This is a first order selective catheter position, (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family). As discussed later, this code needs to be listed twice on the claim form or modified if your doctor performs bilateral selective renal angiography. The radiological supervision and interpretation codes available to report selective renal artery imaging are: (Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation) (Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation) Both of these codes require selective catheterization of the target vessel(s). The first code describes unilateral imaging, the second code describes bilateral imaging. Make sure not to report the flush aortogram performed to assist with the selective catheterization of the renal arteries. The parenthetical note in the definitions of code and establish that each of these services includes flush aortography. Uilateral vs. Bilateral The appropriate code for selective renal artery catheterization is typically (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family). As illustrated by this code definition, it is specific to each first order selective catheterization. Page 2 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 43

53 EXHIBIT D When one renal artery is selectively catheterized it is appropriate to report this code one time. When both renal arteries are selectively catheterized, it is appropriate to report this code two times or one time with the bilateral procedure modifier (50) attached. The appropriate way to report bilateral, selective renal catheterization fluctuates based on payer preference. If you can t identify the appropriate coding methodology from claim payment history, it may be necessary to contact each of your payers to identify their preferences. Following are four of the most common payer preferences for reporting bilateral selective renal artery catheterization: The one liner: The generic two-liner: The anatomic two-liner: LT RT The hybrid two-liner: LT RT-59 While each of these coding combinations may accurately reflect selective catheterization of two renal arteries, payment rates and coverage may be impacted based on which option you choose. It is appropriate to confirm payer preference before submitting claims. The appropriate radiological supervision and interpretation code (75722 vs ) should be reported in addition to the catheter placement code(s). First Order vs. Second Order While most selective renal artery catheterizations are first order procedures (36245), there are cases where the doctor will selectively image from second order selective catheter positions. This will be described as selective catheterization of the superior and/or inferior branch of the renal artery. The initial second order selective position in each renal arterial vascular family should be reported with code (Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family). If both the superior and inferior renal arterial branches are selectively catheterized, the second branch catheterization should be reported with code (Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)). When imaging is conducted from both the superior and inferior branches of a renal arterial vascular family, the initial imaging should be reported with the appropriate selective renal imaging code ( vs ). Each subsequent renal arterial branch study should be reported with code (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure)). Accessory Renal Arteries Most patients have one renal artery supplying each of their kidneys with blood. A little more than 20% of patients have accessory renal arteries. These patients have two separate vascular families supplying either of the kidneys with blood. Doctors commonly reference accessory renal arteries as superior and inferior poles. Since each renal pole is a unique vascular family (they each branch off of the aorta) selective catheterization of each pole should be reported as a first order selective catheterization (36245). An accessory renal artery. The appropriate selective renal angiography code (75722 vs ) should be reported for the initial renal artery imaged on either side of the patient s body. The additional vessel code (75774) should be reported for each accessory renal artery pole. Make sure not to confuse the terms pole and branch. Selective catheterization of a superior renal artery branch increases the level of selectivity within that vascular family. Selective catheterization of the superior renal pole indicates that a separate vascular family is being catheterized. Each vascular family catheterized should have the appropriate first, second, or third order catheterization code assigned ( ). Stand-Alone vs. Concomitant with a Heart Catheterization When renal angiography is performed as a stand-alone procedure the coding rules specific to peripheral vascular procedures prevail. You will Page 3 44 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

54 EXHIBIT D need to accurately assign codes for catheter placement and radiological imaging. When renal angiography is performed at the time of a heart catheterization it is frequently necessary to adjust your approach to coding. If a non-selective study is conducted at the time of a heart catheterization it is necessary to omit the catheter placement code (36200) from your claim form. This is because the code used to report the heart catheterization, (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) includes navigation of the catheter from the access site into the heart and coronary arteries. The non-selective, suprarenal catheter position in the abdominal aorta is along the route that the catheter naturally travels to reach the heart. As such, it is not appropriate to report code in addition to This prohibition is enforced by the Correct Coding Initiative Edit that bundles code into code and does not permit payment regardless of modifier application. Correct Coding Initiative Edits must also be considered when reporting renal angiography at the time of a heart catheterization. The following codes are each bundled into code Unlike code 36200, these codes should be separately reimbursed from code when reported with the appropriate Correct Coding Initiative related modifier (59, LT, or RT): Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family Aortography, abdominal, by serialography, radiological supervision and interpretation Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) As mentioned below, nonselective imaging of the renal arteries at the time of a heart catheterization for a Medicare patient must be reported with a Medicare specific code. Medicare vs. Non-Medicare In spite of the Standardized Transactions and Code Set requirement of the Health Insurance Portability and Accountability Act (HIPAA), it is necessary to report some renal angiograms performed on Medicare patients with a different coding methodology than if the same procedure was performed on a non- Medicare patient. For non-medicare patients it is appropriate to report a non-selective renal angiogram performed at the time of a heart catheterization as a flush abdominal aortogram with code (Aortography, abdominal, by serialography, radiological supervision and interpretation). Under the same circumstances, non-selective renal angiography performed on a Medicare patient should be reported with code G0275 (Renal angiography non-selective, one or both kidneys, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of any catheter in the abdominal aorta at or near the origins (ostia) of the renal arteries, injection of dye, flush aortogram, production of permanent images, and radiologic supervision and interpretation (list separately in addition to primary procedure). By requiring the substitution of code G0275 for code 75625, Medicare is securing a substantial discount. With a current Relative Value of just.37, code G0275 brings in only $14.02 (unadjusted national payment rate). This reflects a 77% discount from the $60.26 payment rate assigned to code Indications for Renal Angiography Keep in mind that renal angiography, as a stand-alone procedure or as an add-on to a heart catheterization, is not currently covered for screening purposes. It is important to familiarize yourself with applicable coverage criteria and to confirm that you only report diagnosis codes that are clearly documented in the patient s record. Incident To Billing (Continued from Pg. 1)... presence must meet Medicare's "direct supervision" requirements. This requires the supervisor to be in the suite of offices maintained by the practice and available to render assistance. However, the supervising provider does not need to be in the same room as the NPP when the service is rendered. If the Incident To requirements are not met it is necessary for the service to be billed under the NPP's name and number. This will result in a 15% payment reduction. However, this is much smaller than the potential penalty that could be assessed for inappropriate billing of services. Page 4 Interventional Radiology: Accurate Coding for Appropriate Reimbursement 45

55 EXHIBIT D Keep the following pointers in mind to avoid common Incident To billing errors: Incident To billing is a Medicare specific requirement. Non-Medicare payers have the freedom to create their own policies specific to NPPs. While it is necessary to check with individual payers to confirm their policies, you should find that most are not nearly as restrictive as Medicare. Physicians can delegate direct supervision of NPPs to other members of a group practice. The Incident To services should be billed under the provider's name that personally provided the direct supervision. Services cannot be billed Incident To if they are rendered in a hospital. New patient visits and consultations cannot be billed Incident To since the "established patient" and "established problem" requirements of the Incident To provision will not be met. NPPs can provide direct supervision for services rendered Incident To their management of patients. While the 15% reduction would still be applied to the service, this provision allows NPPs to supervise other NPPs and Registered Nurses who may be seeing patients when no physician is in the office. In order to bill for the work of an NPP under the Incident To provision, the NPP must represent a direct financial expense to the practice. This requirement is met when the supervised NPP is a "W-2" employee, a leased employee, or an independent contractor. This requirement is not met if the NPP is an employee of another institution or a sales representative of a supplier. Online Proficiency Test Available You can now enjoy online coder proficiency testing! An advanced level test has been set up online which thoroughly assesses reader understanding of the topics presented in this publication. Successful completion of the test generates 2.5 AAPC pre-approved continuing education units for each reader. CEU certificates will be available online after completion of the test. The designated administrator for your practice has been provided a user name and password to access the online publication and proficiency test. Additional users can be set up for online proficiency testing for just $50 each for your entire membership year. Each registered user will receive individual report cards, CEU certificates, and have access to the online publication and test. The designated administrator for each practice will be able to view the report cards for each enrolled employee and maintain documentation of effective training an important element of every effective compliance program. Visit today for a free test drive as a guest user. Plus, enrolled members can now access the February, 2007 publication and proficiency test after logging into the system. Page 5 46 Interventional Radiology: Accurate Coding for Appropriate Reimbursement