Best Practices for Diagnostic Radiology Documentation. Presented by Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC President & Senior Consultant.

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1 Best Practices for Diagnostic Radiology Documentation Presented by Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC President & Senior Consultant April 11, 2016 AAPC HEALTHCON Agenda Diagnostic Test Orders ACR Guidelines CPT Guidelines LCDs ICD-10-CM Coding Copyright all rights reserved. Unauthorized distribution is prohibited. 2 1

2 Diagnostic Test Orders Copyright all rights reserved. Unauthorized distribution is prohibited. 3 Diagnostic Test Orders Why the confusion? Hospital vs. physician practice vs. IDTF Copyright all rights reserved. Unauthorized distribution is prohibited. 4 2

3 Diagnostic Test Orders Why the confusion? Hospital CoP for Medicare (42 CFR ) Radiology services provided only on the order of practitioners with clinical privileges consistent with state law. Authorized by medical staff Physician CoP for Medicare (42 CFR ) All diagnostic tests must be ordered by the treating physician Tests not ordered by treating physician not reasonable and necessary Treating physician Furnishes a consultation or treats a beneficiary for a specific medical problem Uses the results in the management of the beneficiary s medical problem Copyright all rights reserved. Unauthorized distribution is prohibited. 5 Diagnostic Test Orders Why the confusion? IDTF (42 CFR ) All procedures performed must be specifically ordered in writing by the physician treating the beneficiary Supervising physician of IDTF may not order tests, unless he is treating physician for beneficiary May not add procedures based on internal protocols without a written order from treating physician The order must specify the diagnosis or other basis for testing Copyright all rights reserved. Unauthorized distribution is prohibited. 6 3

4 Diagnostic Test Orders & Medical Necessity Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. Medicare may only pay for items and services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member unless there is another statutory authorization (certain screening/preventative exams) for payment. NCDs LCDs Copyright all rights reserved. Unauthorized distribution is prohibited. 7 Diagnostic Test Orders & Medical Necessity Medicare CoP (42 CFR ): CMS charges the referring physician with the responsibility of documenting medical necessity. Balanced Budget Act of 1997 Section 4317(b): The ordering physician must provide signs/symptoms or a reason for performing the test at the time it is ordered. Medicare IDTF CoP (42 CFR ): Order must specify the diagnosis or other basis for testing Medical necessity is determined by those signs/symptoms provided by the ordering physician. Test ordered to rule out a specific condition is considered a screening exam by Medicare. Copyright all rights reserved. Unauthorized distribution is prohibited. 8 4

5 Ordering & Performance of of Diagnostic Tests NOTE: Unless specified, these sections are not applicable in a hospital setting Definitions (Section ) Diagnostic Test: Diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary Treating Physician: Furnishes a consultation or treats a beneficiary for a specific medical problem, and uses the results of a diagnostic test in the management of the medical problem. Radiologist performing a therapeutic intervention = treating physician. Radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician. Treating Practitioner: NP, CNS, or PA, who furnishes a consultation or treats a beneficiary for a specific medical problem, and uses the results of a diagnostic test in the management of the medical problem. MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 9 Ordering & Performance of Diagnostic Tests Definitions (Section ) (cont.) Testing Facility: Includes a physician or a group of physicians (e.g., radiologist, pathologist), a laboratory, or an IDTF. Order: Written document signed by the treating physician/practitioner handdelivered, mailed, or faxed to the testing facility Telephone call by the treating physician/practitioner or his/her office to the testing facility Both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary s medical records. Electronic mail by the treating physician/practitioner or his/her office to the testing facility. MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 10 5

6 Ordering & Performance of Diagnostic Tests Definitions (Section ) (cont.) Orders: No signature is required on orders Physician must clearly document, in the medical record, his or her intent that the test be performed. Orders may conditionally request an additional diagnostic test MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 11 Ordering & Performance of Diagnostic Tests New orders must be obtained when: Test is determined to be clinically inappropriate or suboptimal If the result of an ordered diagnostic test is normal and the radiologist believes another diagnostic test should be performed for correct diagnosis. MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 12 6

7 Ordering & Performance of Diagnostic Tests Testing Facility Furnishing Additional Tests If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply: Test originally ordered performed Based on result additional test necessary Delaying performance would have adverse effect Result is communicated to treating physician and used in treatment Interpreting physician clearly documents why additional tests performed MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 13 Ordering & Performance of Diagnostic Tests Testing Facility Furnishing Different or Additional Tests Test Design # of views, use of contrast, unless specified Clear Error RT vs LT Patient Condition Cancelled/Incomplete MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 14 7

8 Signature Requirements A signature is not required on orders for tests paid under the clinical laboratory or physician fee schedule Ordering physician must clearly document in the medical record his or her intent that the test be performed. (Transmittal 94, CR6100) Some circumstances for which an order does not need to be signed (Transmittal 327, CR6698) If order is unsigned, the treating physician must have documentation (progress note) that he/she intended the clinical diagnostic test be performed. The documentation showing intent must be authenticated by the author via a handwritten or electronic signature. (42 CFR 410 and Pub , Chapter 15, section ) Stamp signatures are not acceptable. Handwritten or electronic signatures are required. (Transmittal 327, CR6698) Copyright all rights reserved. Unauthorized distribution is prohibited. 15 In Summary Can you explain the difference between test order requirements in the hospital setting versus the office and IDTF settings? MBPM Chapter 15, Section 80.6 Unless specified, these sections are not applicable to hospital setting Testing facility : Physician or group of physicians, laboratory, or IDTF. CMS Hospital CoP 42 CFR Practitioners w/ clinical privileges consistent with state law, authorized by medical staff Copyright all rights reserved. Unauthorized distribution is prohibited. 16 8

9 In Summary Does the referring physician need to include signs/symptoms or a diagnosis? Section 4317(b) of the BBA 1997 MCPM Chapter 23, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 17 In Summary If a patient shows up for their scheduled test but they do not have a copy of the test order with them and we have not received the order from the referring physician, can we proceed with the scheduled test? Call ordering physician to request a copy of test order or verbal confirmation If unable to reach physician, do not perform test Copyright all rights reserved. Unauthorized distribution is prohibited. 18 9

10 In Summary If an order is received for a CT or MRI that specifies with contrast can we perform and bill for a without and with contrast exam? Radiologist may determine parameters of test unless specified MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited. 19 In Summary Can the testing facility order additional procedures if the requested exam would not provide the diagnostic information necessary to diagnose and treat the patient? Five conditions: Test originally ordered performed Based on result additional test necessary Delaying performance would have adverse effect Result is communicated to treating physician and used in treatment Interpreting physician clearly documents why additional tests performed MBPM Chapter 15, Section Copyright all rights reserved. Unauthorized distribution is prohibited

11 In Summary May verbal orders be accepted for diagnostic tests? Ordering physician and testing facility must document phone call in patient s medical record Copyright all rights reserved. Unauthorized distribution is prohibited. 21 In Summary Is a signature required on diagnostic test orders? Transmittal 94 (CR 6100) Transmittal 327 (CR 6698) 42 CFR 410 MBPM Chapter 15, Section Are rubber stamps an acceptable means of authentication? Transmittal 327 (CR 6698) Copyright all rights reserved. Unauthorized distribution is prohibited

12 ACR Guidelines Copyright all rights reserved. Unauthorized distribution is prohibited. 23 ACR Guidelines Communication Diagnostic Findings Demographics Relevant clinical information Body of the report Procedures and materials - contrast media and/or radiopharmaceuticals (including specific administered activities, concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Patient reaction or complication should be recorded. Findings Potential limitations Clinical issues Comparison studies and reports Impression (conclusion or diagnosis) Copyright all rights reserved. Unauthorized distribution is prohibited

13 CPT Guidelines Copyright all rights reserved. Unauthorized distribution is prohibited. 25 CPT Guidelines Located in the beginning of each section of CPT Written report, signed by the interpreting physician is an integral part of a radiologic procedure or interpretation. Know and adhere to subsection guidelines Refer to CPT Assistant, Clinical Examples in Radiology as applicable Copyright all rights reserved. Unauthorized distribution is prohibited

14 CPT Guidelines Administration of Contrast With contrast refers to contrast administered: Intravascular, Intrathecal, Intra-articular Injection of IV contrast is part of the with contrast CT, CTA, MRI, MRA For intra-articular injection, use appropriate joint injection code For spine exams with contrast includes intrathecal or intravascular injection. For intrathecal injection, use also or Oral and/or rectal contrast administration alone does not qualify as with contrast study Copyright all rights reserved. Unauthorized distribution is prohibited. 27 CPT Guidelines Ultrasound Guidance Requires permanently recorded images of site to be localized as well as documented description of localization process. Diagnostic Ultrasound Require permanently recorded images with measurements, when measurements clinically indicated Use of US without thorough evaluation or organ(s) or anatomic region, image documentation and final, written report is not separately reportable. Copyright all rights reserved. Unauthorized distribution is prohibited

15 CPT Guidelines Complete vs. Limited Ultrasound All elements must be documented as required or reason for non visualization Surgically absent Obscured by bowel gas Limited codes used once per session, not per organ. Copyright all rights reserved. Unauthorized distribution is prohibited. 29 CPT Guidelines Supervision & Interpretation Both must be provided by the physician to report these codes Must be a formal study and interpretation to report these codes: Epidurography Discography Myelography Arthrography Copyright all rights reserved. Unauthorized distribution is prohibited

16 CPT Guidelines Duplex Scans Combines Doppler & Conventional US Conventional US: view structure of blood vessels Doppler US: view movement and speed of blood through vessels Duplex US produces images that can be color coded to show physicians where blood flow is blocked. Copyright all rights reserved. Unauthorized distribution is prohibited. 31 CPT Guidelines Duplex Scans Use of a hand held or other Doppler device that does not produce a hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow is not separately reported. Duplex scan describes a US procedure for characterizing the pattern and direction of blood flow in arteries or veins with production of real-time images integrating B mode 2 dimensional vascular structure, Doppler spectral analysis, and color flow Doppler imaging Copyright all rights reserved. Unauthorized distribution is prohibited

17 CPT Requirements Duplex Scans Assessing flow with color, recording a waveform and reporting the findings in a medically indicated examination are the key elements to look for in a report. Buzz Words: Waveform normal, spectral Doppler showed no flow, Normal triphasic waveform patterns using Doppler interrogation True vascular analysis must be performed Copyright all rights reserved. Unauthorized distribution is prohibited. 33 Problem Areas Copyright all rights reserved. Unauthorized distribution is prohibited

18 Problem Areas: 3D Rendering D rendering with interpretation of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision; not requiring image post processing on an independent workstation D rendering with interpretation of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision; requiring image post processing on an independent workstation Copyright all rights reserved. Unauthorized distribution is prohibited. 35 Problem Areas: 3D Rendering 3D Rendering (76376 & 76377) assigned for 3D reformatted images Maximum Intensity Projections (MIPs) Shaded surface rendering Volumetric rendering Coronal, sagittal, multiplanar or oblique reformats constructed from axial images are 2D - these reformatted images are not considered 3D rendering 3D Rendering: Requires Concurrent Supervision Design of the anatomic region that is to be constructed Determination of the tissue types and structures to be displayed Determination of the images or cine loops that are to be archived Monitoring and adjustment of 3D work product If the physician is not supervising and/or creating the 3-D reconstructions and archiving the 3-D images, a separate 3D reconstruction code cannot be billed for either the technical component or the professional component. (ACR Coding Source, March/April 2012) Copyright all rights reserved. Unauthorized distribution is prohibited

19 Problem Areas: 3D Rendering Test Orders for 3D Rendering Requested by referring physician with documented medical necessity In the hospital setting radiologists may generate their own order, but medical necessity must be clearly documented 3D codes generally for situations where additional imaging is necessary for surgical planning or for complete depiction of an abnormality from the two-dimensional study. (ACR Radiology Coding Source November/December 2005) Must provide additional information to aid in making a diagnosis and managing the care of the patient. Routine use of 3D add-on codes may be a flag for records-based medical review.. A radiologist may order 3D imaging only when it is clearly essential to interpret a case at hand and answer questions with clear clinical impact and necessity. (Palmetto GBA, Policy L D Interpretation and Reporting of Imaging Studies) Copyright all rights reserved. Unauthorized distribution is prohibited. 37 Problem Areas: 3D Rendering RAC Audit Issue - Connolly Healthcare, RAC Region C Audit focusing on the medical necessity for 3D reconstruction procedures interpreted by the physician Providers were billing for 3D interpretation and reporting of imaging studies found to be not medically appropriate AdvantEdge Copyright all rights reserved. Unauthorized distribution is prohibited

20 Problem Areas: CT vs. CTA CTA primarily focused on evaluating the vessels, however skeletal anatomy and soft tissues also acquired (CT). 3D images must be permanently stored Imaging of the vessels alone not necessarily considered a CTA 3D reconstruction post-processing must be done to evaluate the vessels Keywords: shaded surface, volumetric rendering, quantitative analysis (segmental volumes and surgical planning) and maximum intensity projections (MIPs). Note: same keywords for 76376/76377, bundled w/ CTA Copyright all rights reserved. Unauthorized distribution is prohibited. 39 Problem Areas: CT vs. CTA CT and CTA Same Day Computed tomography (CT) and computed tomographic angiography (CTA) procedures for the same anatomic location may be reported together in limited circumstances. If a single technical study is performed which is utilized to generate images for separate CT and CTA reports, only one procedure, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at separate patient encounters or if two separate and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient encounter. The medical necessity for the latter situation is uncommon. (Chapter 9, NCCI Policy Manual) Copyright all rights reserved. Unauthorized distribution is prohibited

21 Problem Areas: CT vs. CTA CT and CTA Same Day Example: CT of the abdomen reveals a tumor in the head of the pancreas and after consultation a CTA is recommended to identify any vascular invasion of the tumor into the pancreaticduodenal artery. Code CT & CTA. (Reference: Clinical Examples in Radiology, Volume 4, Issue 3; Summer 2008) Copyright all rights reserved. Unauthorized distribution is prohibited. 41 Problem Areas: CT w/ 3D vs. CTA Codes and are assigned when 3D reformatted images are constructed from a CT data set. Maximum intensity projections (MIPs) Shaded surface rendering Volumetric rendering. CTA is used for evaluating the vessels while a standard CT is focused on skeletal anatomy and soft tissue, however even documented CT imaging of the vessels may not be coded as a CTA unless there is specific documentation indicating that 3D reformatted images were produced. CT w/3d: Code 76376/76377 should be reported only one time when multiple base codes are imaged. Copyright all rights reserved. Unauthorized distribution is prohibited

22 Problem Areas: Duplex Studies "Assessing flow with color, recording a waveform and reporting the findings in a medically indicated examination are the key elements to look for in a report. ACR Ultrasound Coding User s Guide Both spectral analysis and color flow must be documented. US imaging Velocity measurements of blood flow. Spectral analysis: acceleration rate, monophasic, biphasic or triphasic waveforms, peak systolic velocity, resistive index (RI), velocity, waveform analysis, pulsed Doppler, spectral Doppler. Color Flow Color Doppler, when used only for structure identification, does not indicate that a duplex study CPT code should be used. Copyright all rights reserved. Unauthorized distribution is prohibited. 43 Problem Areas: Duplex Studies Duplex scan lower extremity arteries or arterial bypass grafts; complete bilateral study Full length of CFA, SFA and popliteal arteries (deep fem and TP may be imaged if indicated) Eval of complete course of LE arterial bypass graft unilateral or limited study Duplex scan upper extremity arteries or arterial bypass grafts; complete bilateral study Subclavian, axillary and brachial arteries (radial and ulnar when indicated) Eval of complete course of UE arterial bypass graft unilateral or limited study ACR Ultrasound Coding User s Guide Copyright all rights reserved. Unauthorized distribution is prohibited

23 Problem Areas: Duplex Studies Duplex scan extremity veins including responses to compression and other maneuvers; complete bilateral study LE: CF, SF, Proximal deep femoral, greater saphenous, and popliteal veins. Calf veins may also be evaluated. UE: subclavian, jugular, axillary, brachial, basilic and cephalic veins. Forearm may also be evaluated unilateral or limited study Reported for upper and lower extremities Report twice to identify an upper and lower extremity study w/ Modifier 59 Copyright all rights reserved. Unauthorized distribution is prohibited. 45 Problem Areas: Duplex Studies Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs, complete Code is used for single organ or multiple organs studied Complete = all major vessels supplying blood flow inflow and outflow with or without color flow mapping to the organ are evaluated limited study Duplex scan of aorta, IVC, iliac vasculature, or bypass grafts, complete Code is used whether one or more vessels are evaluated in entirety Vessels studied in entire intra-abdominal or pelvic course unilateral or limited study ACR Ultrasound Coding User s Guide Copyright all rights reserved. Unauthorized distribution is prohibited

24 Duplex Studies & Medical Necessity The NCCI Manual Chapter 9 says: Abdominal ultrasound examinations (CPT codes ) and abdominal duplex examinations (CPT codes 93975, 93976) are generally performed for different clinical scenarios although there are some instances where both types of procedures are medically reasonable and necessary. In the latter case, the abdominal ultrasound procedure CPT code should be reported with an NCCIassociated modifier. Copyright all rights reserved. Unauthorized distribution is prohibited. 47 Duplex Studies Test Orders Doppler studies should not be added routinely to every ultrasound performed. If the Doppler study is performed and medically necessary based upon the clinical presentation and specific clinical question, then this procedure falls into the test design exception of the Ordering of Diagnostic Tests Rule. However, if an order is not obtained, a detailed explanation by the radiologist in his or her report as to why the Doppler was medically necessary should be documented. Clinical Examples in Radiology Volume 9, Issue 1; Winter 2016 Copyright all rights reserved. Unauthorized distribution is prohibited

25 ICD-10-CM Coding Copyright all rights reserved. Unauthorized distribution is prohibited. 49 Choosing the Primary Diagnosis Code ICD-10-CM Diagnostic Coding & Reporting Guidelines for Outpatient Services. In determining the first-listed diagnosis the coding conventions of ICD- 10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. For patients receiving diagnostic services only during an encounter/ visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. Copyright all rights reserved. Unauthorized distribution is prohibited

26 Choosing the Primary Diagnosis Code ICD-10-CM Diagnostic Coding & Reporting Guidelines for Outpatient Services. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. Copyright all rights reserved. Unauthorized distribution is prohibited. 51 Choosing the Primary Diagnosis Code Confirmed Diagnosis Based on Results of Test Report any confirmed diagnosis Signs and/or symptoms may be reported as additional diagnoses Signs/Symptoms If the diagnostic test did not provide a diagnosis or was normal, the interpreting physician should code the sign(s) or symptom(s) that prompted the treating physician to order the study. On the rare occasion when the interpreting physician does not have diagnostic information as the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician. (Language removed in latest version of MCPM Chapter 23, Section ) Copyright all rights reserved. Unauthorized distribution is prohibited

27 Choosing the Primary Diagnosis Code Uncertainty Do not code the following diagnoses: Probable Suspected Questionable Rule out Working diagnosis Other similar terms indicating uncertainty. Considered by the ICD 10-CM Coding Guidelines as unconfirmed and should not be reported Code to the highest degree of certainty (symptoms, signs, abnormal test results, or other reason for the visit) Copyright all rights reserved. Unauthorized distribution is prohibited. 53 Choosing the Primary Diagnosis Code Incidental findings Never be listed as primary diagnoses. May be reported as secondary diagnoses. Recommended to report any incidental findings that may warrant additional follow-up studies. Unrelated Coexisting Conditions/Diagnoses (optional) May be reported as additional diagnoses by the physician interpreting the diagnostic test. Screening/No signs or symptoms In the absence of signs/symptoms report the screening code as the primary diagnosis code. Conditions confirmed during the screening are reported as a secondary diagnosis. Copyright all rights reserved. Unauthorized distribution is prohibited

28 Choosing the Primary Diagnosis Code Review of Documentation - Test order, radiology report, and any other pertinent documentation. Impression: Review the impression for definitive conditions Clinical indications: Determine of conditions listed in the impression are related to the exam or unrelated incidental findings Summary of findings: Review body of report to clarify impression, beware of incidental findings Select the primary diagnosis code in accordance with coding guidelines. Copyright all rights reserved. Unauthorized distribution is prohibited. 55 Diagnosis Coding FAQs Can I code from the header of the radiology report? Must the body of the report support the exam stated in the header? Do I used the findings or signs/symptoms for coding? pecking order findings on report, clinical indications test order If the radiologist uses the phrase consistent with can I code the condition? AHA CC, 3 rd Quarter 2005 Copyright all rights reserved. Unauthorized distribution is prohibited

29 Diagnosis Coding FAQs Is the phrase evidence of considered a definitive diagnosis? Many of the radiology reports that we code have MVA or trauma listed as the reason for the exam. What ICD 10 code should be assigned in these instances? When the reason for exam is pain can I code as pain of the site being examined? AHA Coding Clinic 3 rd Quarter 2005; 3 rd Quarter 2009; 1 st Quarter 2006 Copyright all rights reserved. Unauthorized distribution is prohibited. 57 Local Coverage Determinations Copyright all rights reserved. Unauthorized distribution is prohibited

30 Local Coverage Determinations Indications Limitations Documentation Requirements Copyright all rights reserved. Unauthorized distribution is prohibited. Local Coverage Determinations LCD Palmetto GBA MAC Part B - 3D Interpretation and Reporting of Imaging Studies (L31773) Coverage Indications, Limitations, and/or Medical Necessity Medicare expects that no more than 20 percent of the total Computerized Tomography (CT) and Magnetic Resonance (MR) imaging of any practice be submitted with 3-D rendering or interpretation, with or without image post-processing. For non-hospital based outpatient services, Medicare expects that the referring physician will generate a written request indicating the clinical need for the additional 3-D imaging, a copy of that request will be maintained by the interpreting physician, and the interpreting physician s report will address those specific clinical issues. In the event that a 3-D interpretation is deemed urgently needed by the radiologist and the referring physician is not immediately available, the radiologist must document the time of the study, the specific need for the study, and a summary of the findings that were urgently transmitted to the practitioner named as the referring physician on the radiology report. Copyright all rights reserved. Unauthorized distribution is prohibited

31 Local Coverage Determinations LCD Palmetto GBA MAC Part B - 3D Interpretation and Reporting of Imaging Studies (L31773) Limitation CPT codes and may be considered medically unnecessary and denied if equivalent information to that obtained from the test has already been provided by another procedure (magnetic resonance imaging, ultrasound, angiography, etc.) or could be provided by a standard CT scan (two-dimensional) without reconstruction. Documentation Requirements..Use of one of the secondary diagnosis codes ( ) in this LCD implies medical necessity for 3-D rendering and interpretation. Documentation supporting medical necessity must be maintained in the medical record along with the written request for the study from the referring physician. Documentation of the time of the study, the specific need for the study, and the summary of the findings that were urgently transmitted to the practitioner named as the referring physician must be maintained by the radiologist and made available to J11 A/B MAC upon request. Copyright all rights reserved. Unauthorized distribution is prohibited. 61 Local Coverage Determinations LCD Palmetto GBA MAC Part B - Local Coverage Article: 3D Interpretations and Reporting of Imaging Studies (A53269) Reasons for Denial All other indications not listed in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD. The medical record does not verify the service described by the CPT/HCPCS code was provided. The service does not follow the guidelines of the related LCD. The service is considered: Investigational Otherwise not covered Never medically necessary. Service(s) rendered is not consistent with accepted standards of medical practice. Lack of documentation supporting the medical necessity of the 3-D rendering or image post-processing. Lack of documentation from the requesting physician authenticating the need for 3-D rendering of the obtained images except as described in urgent situations (in the LCD). Copyright all rights reserved. Unauthorized distribution is prohibited

32 Question & Answer Copyright all rights reserved. Unauthorized distribution is prohibited. 63 Contact Us Visit us on the web Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC President & Senior Consultant 850 NW Federal Highway, Suite 427Stuart FL Copyright all rights reserved. Unauthorized distribution is prohibited