Stay Tuned for Webinar. CBR201506: Computed Tomography (CT) of the Abdomen & Pelvis for Rendering Providers

Transcription

1 Stay Tuned for Webinar Audio dial-in: ; PIN: # For technical assistance contact CBR201506: Computed Tomography (CT) of the Abdomen & Pelvis for Rendering Providers Begins at 3:00 P.M. ET 1

2 CBR201506: Computed Tomography (CT) of the Abdomen & Pelvis for Rendering Providers CPT codes, descriptors, and other data are copyright 2013 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 2

3 The CBR project has made every reasonable effort to ensure the accuracy of the information and web links provided in the CBR materials at the time of publication; however, Medicare policy changes frequently, so the information and links within the material may change without further notice. It is the responsibility of the provider to remain up-to-date with Medicare Program requirements. 3

4 CBR materials are prepared as a service to the public and are not intended to grant rights or impose obligations. The information provided in the CBR material is only intended to be a general summary. It does not supersede or alter the coverage and documentation policies outlined in the local coverage determinations (LCD) and policy articles for the A/B Medicare Administrative Contractors (MAC) or DME Medicare Administrative Contractors (DME MAC). Please refer any specific questions you may have to the A/B or DME MAC for your region. We encourage providers to review the specific statutes, regulations, and other interpretive material for a full and accurate statement of their contents. 4

5 Webinar Outline 1. Introduction 2. Coverage & Documentation Overview 3. Methods & Results 4. References & Resources 5. Q&A 6. Survey 5

6 Webinar Requirements Landline for conference call (cell phones are not recommended) Wired (not wireless) broadband internet connection Not Recommended: Access Points/Mobile Air Connections PC computer using Windows or MAC operating system Android or ipad tablets Latest version of Adobe Flash installed 6

7 Webinar Protocol All attendee lines are muted Submit questions via chat when prompted by speaker Submit questions during the Q&A session at the end of webinar Ask questions pertinent to webinar Contact MAC for specific claims questions 7

8 Webinar Objective Upon completion of this webinar the participant should be able to: Demonstrate a general understanding of CBR201506: Computed Tomography of the Abdomen & Pelvis Comprehend the analytical methods used to develop the report Locate policy references and resources 8

9 Sample CBR Provided for each topic 9

10 CBR Purpose Designed to: Provide education to the provider community Compare billing practices among Medicare providers and their peer groups Gives providers an opportunity to: Check their records against data in CMS files Review Medicare guidelines to ensure compliance 10

11 CBR Focus Diagnostic Radiology for rendering providers (specialty 30) CT of the abdomen and pelvis for: CPT without contrast CPT with contrast CPT with/without contrast 11

12 CBR Comparisons This CBR examines: Percentage of beneficiaries with a previous CT of the abdomen & pelvis from any provider or any place of service (POS) within 365 days Percentage of CTs of the abdomen and pelvis without contrast followed by with contrast of the abdomen and pelvis performed in the emergency room (ER) and inpatient (IP) Percentage of CTs of the abdomen and pelvis without contrast followed by with contrast performed in office or any POS other than ER or IP 12

13 Demographics 5,000 diagnostic radiology providers Medicare Fee-for-Service (FFS) claims data Providers with different billing patterns from their peers for CPT codes 74176, and

14 Webinar Materials References and Resources Webinar slides MP4 of webinar Webinar Handout Webinar Q&A Handout 14

15 Acronyms Code ACR AHRQ BETOS CERT CT LCD MRI OEI OIG RAC Description American College of Radiology Agency for Healthcare Research & Quality Berenson-Eggers Type of Service Comprehensive Error Rate Testing Computed Tomography Local Coverage Determination Magnetic Resonance Imaging Office of Evaluation and Inspections Office of Inspector General Recovery Audit Contractors 2015 Palmetto GBA, Graphic for CBR201506, All Rights Reserved. 15

16 Coverage & Documentation Overview 16

17 Topic Selection Office of Inspector General (OIG) Report OEI Medicare Payments for Diagnostic Radiology Services in Emergency Departments, April

18 2014 CERT Errors 2014 CERT improper payment rate of 13.2% for Advanced Imaging, other BETOS codes, I2B $136,759,856 projected improper payments 93.5% of errors were due to insufficient documentation 18

19 Outpatient Quality Reporting Measure OP 10 Imaging efficiency: percentage of abdomen CT studies that are performed with and without contrast out of all abdomen CT studies performed. 19

20 Official Hospital Compare Data Data.Medicare.gov type search terms here Search.,.,,, Download, Explore, and Visualize Medicare.gov Data Medicare Websites and Directories Developers Sign In to Data Medicare Gov Home -t Hospital Compare -t Use of Medical Imaging ~ Official Hospital Compare Data ~ Displaying datasets in Use of Medical Imaging category. Alphabetical : Hospital Compare General Information Name iii Outpatient Imaging Efficiency - Hospital Use of medical imaging - provider data_ These measures give you 1nformat1on about hospitals' use of medical imaging tests for outpatients Examples of medical imaging tests include CT Scans, MRls, and mammograms. Popularity Type Cl RSS Linking Quality to Payment Payment and Value of Care Number of Medicare Patients iii Outpatient Imaging Efficiency - National Use of medical imaging national data These measures give you information about hospitals' use of medical imaging tests for outpatients Examples of medical imaging tests include CT Scans, MRls, and mammograms. 400 views Ill Patient Survey Results Readmissions, Complications & Deaths iii Outpatient Imaging Efficiency - State Use of medical imaging - state data These measures give you 1nformat1on about hospitals' use of medical imaging tests for outpatients Examples of medical imaging tests include CT Scans, MRls, and mammograms f78 views Timely & Effective Care Showing 3 of 3 20

21 2014 Utilization CT of Pelvis 191,623 services CT of Abdomen 364,748 services CT Abdomen/Pelvis 5,424,219 services 21

22 Trends in Computed Tomography CT Use in the Emergency Department Head - 14% \. Chest - 16% ~ Abdomen - 51 % ~ Year of Exam Other - 19% I ncludes : Spine, Extremities, Neck and Sinuses 2015 Palmetto GBA, Graphic for CBR All Rights Reserved. Data: Trends in Computed Tomography Utilization Rates: A Longitudinal Practice-Based Study, 22

23 Diagnoses Utilization Symptoms, Signs & Ill-Defined Conditions ( ) 1,946,150 Diseases of the Digestive System ( ) Diseases of the Genitourinary System ( ) 1,049,171 1,405,323 Neoplasms ( ) 900, Palmetto GBA, Graphic for CBR All Rights Reserved. Data: CMS Integrated Data Repository (IDR). Data Extracted on April 28, 2015 for Dates of Service January 1, December 31,

24 NCD National Coverage Determination (NCD) for Computed Tomography: CT scans have become the primary diagnostic tool for many conditions and symptoms. 24

25 Abd/Pelvic CT Scan LCDs State/Territory Florida Puerto Rico, Virgin Islands North Carolina, South Carolina, Virginia, West Virginia Alabama, Georgia, Tennessee First Coast Service Options, Inc. First Coast Service Options, Inc. Palmetto GBA Cahaba Government Benefit Administrators LCDs L28806, L29119 L28813, L29137 L31596, L31597 L Palmetto GBA, Graphic for CBR201506, All Rights Reserved. 25

26 LCDs in Practice Coverage Instructions Documentation Requirements Utilization Guidelines Coding Requirements 26

27 Clinical Indications Evaluation of pain Evaluation of known or suspected abdominal or pelvic masses or fluid collections, primary or metastatic malignancies, abdominal or pelvic inflammatory processes, and abnormalities of abdominal or pelvic vascular structures 27

28 More Clinical Indications Evaluation of known or suspected primary breast cancer metastasis Evaluation of abdominal or pelvic trauma Evaluate lymphadenopathies Clarification of findings from other imaging studies or laboratory abnormalities 28

29 And More Clinical Indications Evaluation of known or suspected congenital abnormalities of abdominal or pelvic organs Guidance for interventional, diagnostic, or therapeutic procedures within the abdomen or pelvis Treatment planning for radiation therapy, follow up radiation therapy 29

30 Limitations No absolute limitations on coverage Claims are reviewed for evidence of abuse Absence of reasonable indications Excessive number of scans Unnecessarily expensive types of scans 30

31 Documentation Requirements Formal written, interpretive report Name of interpreting provider Reason for the test Copies of all images Written/electronic request for procedure which supports medical necessity 31

32 Medical Necessity Relevant medical history Physical examination Diagnosis (if known) Pertinent signs and symptoms Results of pertinent diagnostic tests/procedures 32

33 Methods & Results 33

34 Report Data Medicare Part B Rendering Provider Located by National Provider Identifier (NPI) Specialty 30 (Diagnostic Radiology) CPT codes for CT of abdomen and pelvis: Without contrast (74176) With contrast (74177) Without contrast followed by with contrast (74178) 34

35 Report Data Additional Info Exclusions: Claims with only the technical component Claims with a diagnosis of malignancy Substantial Variation by Place of Service: ER and Inpatient Office and Other 35

36 Peer Groups State Medicare providers in the provider s state Specialty of 30 Selected Codes National All Medicare providers in the Nation Specialty of 30 Selected Codes 36

37 Data Source CMS Integrated Data Repository (IDR) Extracted: April 28, 2015 Dates of Service: January 1, 2014 December 31,

38 Table 1 CPT Code TOTAL Table 1: Summary of Your Utilization January 1, December 31, 2014 Place of Allowed Abbreviated Description Service Charges CT, abdomen and pelvis, w / o contrast ER / In patient $4, CT, abdomen and pelvis, w / o contrast Office/ Other $6, CT, abdomen and pelvis, w / contrast ER / Inpatient $1, CT, abdomen and pelvis, w / contrast Office/ Other $1, CT, abdomen and pelvis, w / o contrast followed by w / contrast ER / Inpatient $2, CT, abdomen and pelvis, w / o contrast followed by w / contrast Office/Other $8, $24, Allowed Be neficiary Services Count

39 Comparison Outcomes There are four possible outcomes: 1. Significantly Higher 2. Higher 3. Does Not Exceed 4. Not Applicable (N/A) 39

40 Percentage of Beneficiaries with Previous CT of Abdomen & Pelvis Calculated as follows: ( Total Number of Your Beneficiaries with a Previous CT) Total Number of Your Beneficiaries xloo 40

41 Table 2 Table 2: Percentage of Beneficiaries with a Previous CT of the Abdomen and Pelvis January 1, December 31, 2014 Your Your State's National Percentage Percentage Comparison with Percentage Comparison with of of Your State's of the National Type Beneficiaries Beneficiaries Percentage Beneficiaries Percentage Previous CT Red 26% 36% Does Not Exceed 34% Does Not Exceed A chi-s q uare was used m this anal y sis ' a l p ha=

42 Percentage of CTs of the Abdomen & Pelvis Without Contrast Followed by With Contrast Performed in ER or Inpatient Hospital Calculated as follows: 42

43 Table 3 Table 3: Percentage of CTs of the Abdomen and P elvis Without and With Contrast Performed in the ER or Inpatient Hospital January 1, D ecember 31, 2014 Your Your State's National Percentage Percentage Percentage of CTs of CTs of CTs Without and Without and Comparison with Without and Comparison with With With Your State 's With the National Type Contrast Contrast P ercentage Contrast Percentage ER / Inpatient 24% 2% Significantly Higher 3% Significantly Higher A ch i-s q ua re test was used m t his anal y sis ' al p ha=

44 Data for Provider Values in Table 3 Table 1: Summary of Your Utilization January 1, December 31, 2014 CPT Place of Allowed Allowed.. Be neficiary Code Abbreviated Description Service Charges Services Count CT, abdomen and pelvis, w / o contrast ER / In patient $4, CT, abdomen and pelvis, w / o contrast Office/ Other $6, CT, abdomen and pelvis, w / contrast ER / Inpatient $1, CT, abdomen and pelvis, w / contrast Office/ Other $1, CT, abdomen and pelvis, w / o contrast followed by w / contrast ER / Inpatient $2, CT, abdomen and pelvis, w / o contrast followed by w / contrast Office/Other $8, TOTAL $24,

45 Calculation for Provider Values in Table 3 CTs Without and With Contrast Performed in ER or Inpatient Hospital Total CTs Performed in ER or Inpatient Hospital xxxx xxxx = 91 xxxx 24% 45

46 Percentage of CTs of the Abdomen & Pelvis Without Contrast Followed by With Contrast Performed in Office or Other POS Calculated as follows: ( CTs Without and With Contrast Performed in Office or Other POS) Total CTs Performed in Office or Other POS 100 x 46

47 Table 4 Table 4: Percentage of CTs of the Abdomen and Pelvis Without and With Contrast Performed in the Office or a POS Other than ER or Inpatient Hospital January 1, December 31, 2014 Your Your State's National Percentage Percentage Percentage of CTs of CTs of CTs Without and Without and Comparison with Without and Comparison with With With Your State's With the National Type Contrast Contrast Percentage Contrast Percentage Office/ Ot her 47% 19% Significant ly Higher 22% Significantly Higher A chi-square t est was used m t his analysis, alpha=

48 Data for Provider Values in Table 4 Table 1: Summary of Your Utilization January 1, December 31, 2014 CPT Place of Allowed Allowed Be neficiary Code Abbreviated Description Service Charges Services.. Count CT, abdomen and pelvis, w / o contrast ER / In patient $4, CT, abdomen and pelvis, w / o contrast Office/ Other $6, CT, abdomen and pelvis, w / contrast ER / Inpatient $1, CT, abdomen and pelvis, w / contrast Office/ Other $1, CT, abdomen and pelvis, w / o contrast followed by w / contrast ER / Inpatient $2, CT, abdomen and pelvis, w / o contrast followed by w / contrast Office/Other $8, TOTAL $24,

49 Calculation for Provider Values in Table 4 CTs Without and With Contrast Performed in Office or Other POS Total CTs Performed in Office or Other POS xxxx x xxxx = 181 xxxx 47% 49

50 References & Resources 50

51 Computed Tomography LCDs & NCD Medicare Coverage Database: Cahaba Government Benefit Administrators L30048 First Coast Service Options, Inc. L28806, L28816, L29119, L29137 Palmetto GBA L31596, L31597 NCD:

52 CMS Hospital Outpatient Quality Reporting Program: Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html Berenson-Eggers Type of Service (BETOS): Comprehensive Error Rate Testing (CERT) The Supplementary Appendices for the Medicare Fee-for-Service 2014 Improper Payments Report Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports Items/Downloads/AppendicesMedicareFee-for Service2014ImproperPaymentsReport.pdf?agree=yes&next=Accept 52

53 Medicare Learning Network Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors Provider Compliance Tips for Computed Tomography (CT Scans) Medicare Payments for Diagnostic Radiology Services in Emergency Departments Complying With Medical Record Documentation Requirements Medicare Learning Network: 53

54 Medicare Manual & OIG Report Medicare Benefit Policy Manual Chapter 15 Covered Medical and Other Health Services Section Guidance/Guidance/Manuals/downloads/bp102c15.pdf Office of Inspector General Medicare Payments for Diagnostic Radiology Services in Emergency Departments 54

55 Additional Resources American College of Radiology (ACR) & Society for Pediatric Radiology (SPR) ACR-SPR PRACTICE PARAMETER FOR THE PERFORMANCE OF COMPUTED TOMOGRAPHY (CT) OF THE ABDOMEN AND COMPUTED TOMOGRAPHY (CT) OF THE PELVIS Agency for Healthcare Research and Quality (AHRQ): National Quality Measures Clearinghouse Imaging efficiency: percentage of abdomen CT studies that are performed with and without contrast out of all abdomen CT studies performed QualityNet.org Imaging Efficiency Measures 2FQnetTier2&cid=

56 Government Resources U.S. Food and Drug Administration: Computed Tomography (CT): EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX Rays/ucm htm Pub Med.gov: Trends in computed tomography utilization rates: a longitudinal practice-based study: Medicare.gov: Hospital Compare: Data.Medicare.gov: Outpatient Imaging Efficiency National Outpatient Imaging Efficiency State 56

57 CBR Website About Us CBR Releases CBR Support Education Recommended Links FAQs Contact Us 57

58 FAQs General FAQs CBR Specific FAQs CBR201506: CT of the Abdomen & Pelvis 58

59 Provider Self-audit Providers and suppliers have an obligation to ensure claims are submitted to Medicare correctly Self-audits allow providers and suppliers to identify coverage and coding errors Refer to the following CBR sections for assistance Documentation and Billing References 59

60 CBR Support Help Desk Monday Friday: 9:00 a.m. to 5:00 p.m. ET Toll Free cbrsupport@eglobaltech.com 60

61 Contacting MACs Providers should contact the Medicare Administrative Contractor (MAC) for assistance with: Claim Information Documentation Requirements Billing and Coding 61

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63 Questions & Answers 0 63

64 We make every effort to address all questions submitted during our webinars. However, we cannot provide responses related to coding issues or to specific claims/scenarios. Since your Medicare Administrative Contractor (MAC) makes the determination to pay or deny a claim based on the CPT codes, medical documentation and description of the circumstances, and we do not have access to this documentation, we cannot respond to these types of questions. Please contact your MAC with questions that we do not address or if you identify any claims discrepancies while reviewing your CBR. The contact information for your MAC is located at 64