Clinical Examples in Radiology, 2005

Volume 1, Bulletin 1

Article Title
Coding Issues Surrounding Settlement of $2.5 Million in Florida

Coding Issues Surrounding Settlement of $2.5 Million in

Florida
The recent $2.5 million settlement between the Department of Justice and a radiology practice in Florida
(http://oig.hhs.gov/fraud/cia/index.html) has attracted the attention of many radiology practices. Although the
details of that settlement are sealed, the information available to the public has raised questions among many
physicians, group practices, coders, and compliance officers. The ensuing discussion highlights issues of
importance to radiology practices.

Clarification of Issues Surrounding the Settlement

It is critical that all radiologists document the performance of procedures by issuing a formal report, note the
medical necessity of all procedures, and adhere to rules (eg, 410.32 “Ordering of Diagnostic Tests” rule for
office procedures) appropriate for the respective sites of service. Practices failing to do so may find difficulty
defending their practice patterns in the event of an audit. Last year, for example, a radiology practice in Fort
Myers, Florida, paid $2.5 million to settle charges that it filed false Medicare claims. The services in question
included reconstruction imaging, non-invasive physiologic studies with duplex Doppler imaging and abdominal
with retroperitoneal ultrasound. Issues pertinent to the coding and reporting of these services are discussed in
the following sections.

CPT Coding Issues

Image Reconstruction – Use of 76375: Reconstruction imaging is considered part of the study design
determined by the radiologist. Accordingly, it is not necessary to obtain a separate order from the referring
physician for the performance of, and coding for, reconstruction imaging when medically necessary. It is the
interpreting radiologist who should ultimately decide whether to create postprocessed images, just as he or she
decides other technical parameters, such as the use of contrast or the use of computer aided detection (CAD) in
conjunction with mammography.

Currently, code 76375 is legitimately coded by the radiologist if it is medically necessary to include 2-
dimensional (2D) and/or 3-dimensional (3D) reconstructions to accurately interpret the examinations.

When 2D and/or 3D reconstruction is medically necessary and is performed on cross-sectional imaging data
(eg, computed tomography [CT] or magnetic resonance imaging [MRI]), it should be reported in addition to
codes for the original cross-sectional imaging study. So that this is clearly identifiable as a separate and
additional service beyond the base procedure, it is recommended that this be described in a separate report or at
least in a separate section of a combined report. Documentation must be included to address the need for
additional post-processed images to justify medical necessity. This cannot just be personal preference.

While it may be helpful to use 76375 in selected cases (eg, characterizing a chest wall mass or evaluating the
cervical spine in the setting of trauma), it is not appropriate to routinely code 76375 as part of every CT or MRI
examination. Practices that liberally use CPT code 76375, particularly as part of universal standing protocols,
are cautioned that they may face a higher level of scrutiny than practices that use the code judiciously on a case-
by-case basis. Documentation of the reason for the reconstruction imaging in the radiology report is absolutely
necessary if 76375 is to be submitted without an order from the referring provider.

Note that code 76375 is used to report studies that have been reformatted from one plane into another (eg, when
images originally acquired in the axial plane are reformatted into the coronal plane). It should not be used to
report imaging originally performed in the coronal, sagittal, multiplanar, and/or oblique planes.1

Noninvasive Physiologic Studies Performed in Conjunction With Duplex Scans: In 2003, the CPT Editorial
Panel clarified introductory language in the CPT codebook to address the distinction between duplex scanning
and non-invasive physiologic studies. Page 299 of the standard edition of the CPT 2005 codebook (Noninvasive
Vascular Diagnostic Studies section) states:

Duplex scan (eg, 93880, 93882) describes an ultrasonic scanning procedure for characterizing the pattern and
direction of blood flow in arteries or veins with the production of real time images integrating B-mode two-
dimensional vascular structure with spectral and/or color flow Doppler mapping or imaging.

Non-invasive physiologic studies are performed using equipment separate and distinct from the duplex scanner.
Codes 93875, 93965, 93922, 93923, and 93924 describe the evaluation of non-imaging physiologic recordings
of pressure, Doppler analysis of bi-directional blood flow, plethysmography, and/or oxygen tension
measurements appropriate for the anatomic area studied.

When performed and medically necessary, it is appropriate to code 93875, Non-invasive physiologic studies of
extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular
pneumoplethysmography, Doppler ultrasound spectral analysis), with 93880, Duplex scan of extracranial
arteries; complete bilateral study, and to code 93965, Non-invasive physiologic studies of extremity veins,
complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers,
phleborheography, impedance plethysmography), with 93970, Duplex scan of extremity veins including
responses to compression and other maneuvers; complete bilateral study, or 93971, Duplex scan of extremity
veins including responses to compression and other manueuvers; unilateral or limited study. There are no
National Correct Coding Initiative edits in place because these code combinations are neither mutually
exclusive nor comprehensive to one another. However, it is not appropriate, as a routine general practice or
standing protocol, to perform both studies together. If one study is ordered and the interpreting radiologist feels
the other is necessary to complete the evaluation, the appropriate rules (based on site of service) should be
followed before adding the additional study. The need for performance of both studies should be judged on a
case-by-case basis and with clear documentation of medical necessity provided.1

Abdominal and Retroperitoneal Ultrasound: While it is unusual for both abdominal and retroperitoneal
ultrasound codes to be performed together on a routine basis, certain clinical circumstances may compel the
need for complete examinations of both the abdomen and the retroperitoneum. Clinical rationale for why both
studies were done, particularly in the absence of an order for both, should be reported. If one study is ordered
and the interpreting radiologist feels the other is necessary to complete the evaluation, the appropriate rules
(based on the site of service) should be followed before adding the additional study. Please refer to the
following discussion of the
Ordering of Diagnostic Tests Rule. Standing protocols for adding a retroperitoneal ultrasound study to the order
for an abdominal ultrasound study are strongly discouraged. This code combination is considered unusual and
should be used only on an individualized case-by-case basis.

Other Coding and Ordering Issues

Other key lessons from the Florida case include issues regarding the Ordering of Diagnostic Tests Rule and
issues regarding appropriate ICD-9-CM coding.1

Ordering of Diagnostic Tests Rule: This Medicare rule applies to freestanding and independent diagnostic
testing facilities, not to hospitals or hospital out-patient facilities. In such nonhospital facilities, an order from
the treating physician is required for all diagnostic tests. An order is defined as a written communication
(original or faxed); a communication by telephone (both treating and providing physicians must note this in
their records); or an e-mail communication. If the provider feels that additional tests are indicated but is unable
to reach the referring physician, then he or she may perform additional tests “if: (1) the diagnostic test ordered
by the treating physician or practitioner is performed;” (2) the radiologist determines that an additional
diagnostic test is medically necessary due to abnormal results of the diagnostic test performed; (3) a delay in
additional testing would have an adverse affect on the beneficiary; (4) the treating physician is notified of the
results of the test and uses the results in the treatment of the patient; and (5) the radiologist documents in the
report why additional testing was necessary. (It is important to document the reason in reports of both the
original and the added study.) Under the interpreting physician exemption to the ordering physician rule, a
radiologist may perform the following without notifying the treating physician.

Unless specified in the order, the radiologist may:

• Set the protocol for a given diagnostic, interventional, or therapeutic procedure ordered (eg, number of
radiographic views obtained, thickness of tomographic sections acquired, use or nonuse of contrast
media);
• Modify an order with clear and obvious errors (eg, an X-ray of the wrong foot is ordered);
• Cancel an order because the beneficiary’s physical condition at the time of the diagnostic testing will not
permit performance of the test (Any medically necessary preliminary or scout studies performed prior to
the canceled order should be coded).2

A radiologist protocoling reconstruction imaging (76375) when medically necessary is included in the
interpreting physician exemption to the Ordering of Diagnostic Test Rule.

Conditional Test Requests: The use of conditional orders has been approved by the Centers for Medicare and
Medicaid Services (CMS) as long as they are limited to a specific beneficiary. For example, the radiologists
may add the ultrasound study to characterize the mass if a patientspecific order reads: “Diagnostic mammogram
of right breast with ultrasound if mass identified.” A standing order for all patients of a given requesting
physician (eg, “if gallbladder ultrasound for Dr Smith is negative, do UGI”) is not acceptable.3

ICD-9-CM Coding: The Florida case also reinforces the need for radiologists to communicate with referring
physicians and to document any efforts to obtain adequate orders and clinical indications for a requested study.
State laws on documentation requirements vary. An order, by definition, is a separate document from the final
radiology report; but when additional information is provided to the radiologist, it is recommended that this be
included as part of the report. Additional information on appropriate communication strategies to obtain
adequate clinical information for requested examinations from referring radiologists can be found on the ACR’s
Web site (www.acr.org/s_acr/bin.asp?CID=541&DID=12196&DOC=FILE.PDF).
By law, the Balanced Budget Act (BBA) of 1997 requires that physicians or practitioners ordering diagnostic
tests provide sufficient diagnostic information so that testing entities performing those tests can submit accurate
claims. CMS issued program memorandum (PM), transmittal AB-01-144 on September 26, 2001, to all carriers
and intermediaries on ICD-9-CM coding for diagnostic tests. CMS clarified that: (1) CMS supports the use of
the Official ICD-9-CM Guidelines for Coding and Reporting; (2) the ICD-9-CM rules apply to the hospital
outpatient and office settings; and (3) radiologists may code the findings from the radiology examination as a
primary diagnosis on the CMS claim form (ie, the radiologist should code the findings from the radiology
examination as the primary diagnosis if more specific than the indication given by the referring physician for
the examination, except for a screening study in which case the screening ICD-9-CM code is used as the
primary diagnosis irrespective of the findings from the radiology examination).

The clarification stated that when the interpreting physician does not have diagnostic information on 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. As stated in the Medicare Claims
Processing Manual, Chapter 23, 10.1.2(A) an attempt should be made to confirm any information obtained from
the patient by contacting the referring physician.

It is essential to accurately and completely document medical necessity and the procedure performed, especially
when there is no order from a referring physician. When researching issues and addressing questions, coders
and compliance officers are always strongly urged to consult original source documents, such as the Code of
Federal Regulations, the Medicare Program Manual, the Federal Register and other authoritative sources for
coding guidelines.

Endnotes

1. ACR Radiology Coding Source. July-August 2004.

2. Medicare Carriers Manual, Section 15021(E)(1-3).
3. ACR Bulletin. November 2001

Reference

ACR Radiology Coding Source. November-December 2004.