hospital side, it is not appropriate to generate a separate charge since the base CT
code includes any non-3D reformatting.
Again, this is a situation where work is performed by the technologist without an
appropriate mechanism to capture the
work/time through the CDM.
No other department has the same challenges that
radiology endures and it is not anticipated this will
change in the near future.
In addition to the specific scenarios previously discussed, there are other bundling
guidelines that impact what can be
charged. Unbundling is defined as the
billing of multiple procedure codes for a
group of procedures that are covered by a
single comprehensive code. Unbundling
can occur unintentionally, due to a misunderstanding of coding guidelines, or intentionally, when a provider manipulates
codes in order to unethically increase the
payment. Sometimes facilities inadvertently “unbundle” because they are seeking
to capture productivity numbers.
Here are some examples of unbundling:
CMS published the National Correct
Coding Initiative Policy Manual, which
describes the principles on which its NCCI
edits are based. You can find the manual on
the CMS website at: http://www.cms.hhs.
How to Address
Since there are many scenarios that clearly
don’t demonstrate the true work performed in the department, what can an
administrator do to provide staffing justification?
First, reevaluate the system utilized for
tracking productivity. While the hospital
administration may want every department to utilize the same source for data
tracking, I would argue that radiology is a
unique department and that special consideration should be given to allowing this
data to be captured through the RIS
instead of the CDM. No other department
has the same challenges that radiology
endures and it is not anticipated this will
change in the near future.
If you are able to use the RIS data you
may not need to read any further. If you
still must utilize the CDM data, you must
find a way to validate its accuracy or,
should I say, determine the actual difference between the data and reality. If your
monthly reports indicate that your average
number of diagnostic exams is 6000 but
you know from your RIS system that your
number is really 7000, then you must
argue for the use of a multiplier when evaluating your data. For example, in the scenario just mentioned, the CDM data
demonstrate a 14.2% variance. An argument could be made that the monthly data
should be multiplied by 1.142 to accurately
reflect the number of exams truly performed. Clearly, you would need to have a
significant enough sample to justify your
number, not just one month’s data.
It can be frustrating to justify staffing levels
based on flawed data, but that does not
justify incorrect billing practices. The best
practice is to use the most accurate data
available. It is worth the time and effort to
evaluate your current data sources and
consider alternatives to ensure that you are
armed with the right data to support your
1Centers for Medicare and Medicaid Services.
National Correct Coding Initiative Policy
Manual for Medicare Services. Version 15. 3.
Chapter IX. Effective October 1, 2009. Available at: http://www.cms.hhs.gov/National-CorrectCodInitEd/. Accessed August 6,
• Coding component parts of a procedure
with separate CPT® codes (eg, esophagram in conjunction with UGI studies –
the esophagram is part of the UGI)
• Reporting separate codes for related services when the code for the primary procedure includes all related services (eg,
cannot report monitoring, IV access, etc)
• Coding a unilateral service twice instead
of coding the one bilateral code (usually
found in IR versus diagnostic services)
• Downcoding a service in order to use an
additional code when one higher level,
more comprehensive code is appropriate
(eg, coding a two view abdomen series
and a single view chest x-ray instead of
the abdominal series that includes both
Melody W. Mulaik is president and co-founder of
Coding Strategies, Inc. She is a nationally recognized
speaker and has delivered numerous presentations at
AHRA annual meetings and conferences. Mulaik is a
member of AHRA, has published extensively, and may be
contacted at firstname.lastname@example.org.
CMS uses National Correct Coding Initiative
(NCCI) edits to rebundle services that were
billed separately (unbundled) by the provider.
Most payors use the NCCI edits, and many
also use additional proprietary edits (eg,
ClaimCheck®). As a result, services that are
considered separately payable by some payors
could be bundled by other payors.