Radiology - Revenue Enhancement & Compliance Review Services
radiology is a rapidly expanding hospital service area. Expansion is occurring
through the volume of services, increasing technological sophistication and a
wider range of services. The rapid expansion of services creates gaps in
hospitals ability to properly code, bill and be appropriately reimbursed for
these special services. Medicare’s implementation of APCs (Ambulatory Payment
Classifications) implementation of various APG (Ambulatory Patient Groups) type
payment systems and a host of other payment mechanisms further complicates the
coding and billing process.
radiology includes special areas such as:
Laboratory (Cath Lab)
Electrophysiological Procedures (EP Lab)
special interventional radiology services should be major profit centers for
hospitals. However, these areas represent major challenges for coding, billing
and assuring compliance. Through careful structuring, organization, proper
coding, good documentation, up-to-date fee schedules and a properly organized
Charge Masters hospitals can improve:
The Quality Of
Care Through Proper Procedural Flow
And Patient Satisfaction
The Quality And
Appropriateness Of Documentation
Of Physician Fees And Hospital Charges
Adherence To Coding and Billing Rules
Under APCs, APGs and Other Payment Systems
Using an Integrated Approach to the IR Challenge
for addressing both revenue enhancement and compliance conformance for
Interventional Radiology is to bring expertise together from several different
areas. The following areas must be considered individually and also integrated
as a whole.
Coding – Radiology, Surgery & E/M
Fee Structuring – RBRVS – Radiology & Surgery
Documentation Process & Compliance Standards
Claims Filing & Processing – CMS-1500
Coding – Radiology, Surgical & E/M - Modifiers
Development - Facilities - Supplies - Drugs
Charge Structuring & Charge Algorithms
10. Facilities Coding – Charge Master Versus Coding Staff
11. Interfaces – Recovery - Observation - Inpatient
12. Organizational Structuring & Physician-Hospital
Add to this
list other clinical concerns such as outcomes management, expensive technology,
and patient satisfaction along with general concerns of efficiency and
effectiveness, and it is little wonder that the rapidly growing Interventional
Radiology area presents a complex opportunity for both physicians and
for hospitals to meet the twin goals of:
Paid (Revenue Enhancement), and
Compliance (Compliance Adherence);
combination of skills, abilities and characteristics on the part of hospitals.
Interventional Radiology Revenue Enhancement & Compliance Review
of improving revenue generation while maintaining compliance varies according
to the size and type of a give hospital and/or system of hospitals. The
following provides a generic outline of the necessary activities to meet
revenue enhancement and compliance goals.
Tasks and Activities
activities involved in addressing both revenue enhancement and compliance
Review of the radiology
and associated surgical/medical procedure sections of the Charge Master including
ancillary areas directly involved with interventional radiology services,
A review of the overall
interventional radiology services, documentation, coding, claims filing and
coding/billing policies and procedures,
Review of the
organizational structure involving the IR including both formal and informal
arrangements including use of non-physician providers,
compliance for both service provision, coding, billing and professional versus
technical code correlation,
activities for coding, billing and IR staff personnel,
an organizational infrastructure to address interventional radiology coding,
billing and compliance issues.
consulting activities and steps are outlined below.
Prior to On-Site Visit
Review of the
Charge Master sections for radiology, catheterization laboratory, vascular
laboratory, and EP services along with identification of any problem areas with
coding, charges, modifiers, etc.
coding/billing policies and procedures in the IR areas.
Review of order
entry, encounter forms, charge sheets and other mechanisms for coding and charge
service-coding-billing process flow.
Revenue Enhancement Team (Business Office, Finance, HIM, IS, and IR service
personnel) concerning overall process, objectives and schedule of activities.
Review of how
the Charge Master entries are being used, encounter form utilization, computer
system capabilities and any associated flow problem areas.
An audit of a
sample of cases (claims, detailed statement and documentation) is performed for
each IR area. This includes:
proper code development for both physician and facilities coding including
compliance concerns (e.g. correlation of physician and hospital coding).
proper reimbursement and any associated problems (e.g. CMS’s Correct Coding
Charge Master and computer system interfaces relative to static and dynamic
coding and proper generation of UB-92s and CMS-1500s.
assessment of the organizational structure for the IR service areas including
any ‘under arrangement’ situations.
charge master personnel relative to recommended changes in the Charge Master.
10. Meeting with HIM coding personnel relative to coding
problems and associated documentation concerns.
11. Meeting with IR staff relative to compliance
12. Meeting with the Revenue Enhancement Team to discuss
findings of the on-site assessment.
13. Meeting with the IR physicians as appropriate to
discuss any recommendations relative to their activities and to discuss any
possible compliance concerns.
14. Training session(s) for IR coding, billing and IR service
area personnel relative to the documentation, billing, coding, and
After Visit Activities
final report concerning the assessment and recommendations relative to coding,
Charge Master, documentation, APC/APG utilization and possible compliance
On-Going Review Activities
and training sessions are provided to continue the process of revenue
enhancement and proper compliance.
services through e-mail, FAX and/or telephone conference calls are also
deliverables fall into two categories:
guidance during the on-site visit,
detailing findings and making recommendations for changes,
revenues from IR activities, and
the final report will address any changes that need to be considered for optimization
of revenues under various outpatient payment systems.
the services must be developed after a specific program of services has been
Distinguishing Characteristics of Abbey & Abbey, Consultants,
are highly educationally oriented.
Almost all studies involve special training for those participating in the
One of our goals
is to provide our clients with the infrastructure
and resources to be independent for
ongoing maintenance activities so that continuing consultation is generally not
All of our
services in the Charge Master and Revenue Enhancement areas include careful consideration of compliance issues.
We will also
review and address APC/APG issues
both for the current implementations and future implementations.
will also be given to any organizational
structuring that can enhance current revenues and/or future
Access to a wide
range of consultative and legal expertise in the health care field through our
membership in the Health Care Consulting
Duane C. Abbey, Ph.D., CFP
Abbey & Abbey, Consultants, Inc.
P.O. Box 2330
Ames, IA 50010-2330
TEL=515-232-6420 e-mail: Duane@aaciweb.com
FAX=515-232-7496 WWW: http://www.aaciweb.com