Virtual colonoscopy billing has been likened to creative writing -- for fun, that is, not profit -- because it so rarely pays. Indeed, one of the most plausible ways of getting reimbursed for the exam involves writing a convincing essay.
U.S. radiologists are all too aware there's no procedure code for screening virtual colonoscopy, and they know there won't be one until any number of organizations, including the U.S. government, deign to approve the procedure sometime during the next two to five years, or so it is hoped.
Not everyone knows, however, that a little knowledge of current reimbursement procedures can sometimes get radiologists paid for the virtual exam -- or at least keep them out of trouble while they're performing it.
Joshua Rolnick, who directs the 3-D surgical planning lab as well as virtual colonoscopy billing at Brigham and Women's Hospital (B&W) in Boston, discussed his hands-on experience with VC reimbursement at the 2003 Symposium on Virtual Colonoscopy in Boston.
"CPT codes really determine what you receive in reimbursement," he said. "For Medicare there's a specific reimbursement for every code, but even for other payors, the reimbursement is based indirectly on the Medicare reimbursement. So it's all tied together."
In order to reimburse for diagnostic colonography or VC, Medicare requires that the patient present with symptoms, rectal bleeding for example. Medicare lists more than 200 symptoms, in fact, and most other payors' lists of symptoms follow the CMS example quite closely, Rolnick said.
As for screening VC, large payors such as Medicare and Blue Cross Blue Shield don't really cover them. Still, Rolnick said, a number of smaller payors offers a bit more flexibility, allowing radiologists to make their best case for reimbursement of a virtual exam for the asymptomatic patient.
There are many reasons why screening VC isn't reimbursed, "but the most important is the lack of consensus of data on its use," he said. "It's still considered investigational rather than a fully clinical procedure. And particularly with Medicare, it's always an uphill road to get coverage for screening exams."
As a result, it is the patient who pays the full cost of VC most of the time. The insurer can be billed first, of course, but the patient must be made aware of his financial responsibility in no uncertain terms before undergoing VC.
The patient should sign a waiver whenever he is responsible for payment, Rolnick said. In fact, Medicare requires it.
"Often (non-Medicare) payor contacts require waivers, and even if they don't it's still good hospital policy to use them, and it also serves as a sort of informed consent," he said. The waiver has to be signed before the procedure, and the waiver has to be individual for that (CT) colonography."
Code |
CPT codes used for virtual colonoscopy exams* |
| 72192 | Computerized axial tomography, pelvis; without contrast material |
|
72193 |
With contrast material(s) |
|
72194 |
Without contrast material, followed by contrast material(s) and further sections |
| 74150 | Computerized axial tomography, abdomen; without contrast material |
|
74160 |
With contrast material(s) |
|
74170 |
Without contrast material, followed by contrast material(s) and further sections |
|
76375 |
Coronal, sagittal 3-D reconstruction |
|
76499 |
Not otherwise classified (NOC) |
|
*Recommended: CT abdomen + pelvis + 3-D for diagnostic VC; NOC for screening VC. |
As for the choice of codes, the B&W staff have found it best to bill for CT abdomen plus pelvis plus 3-D reconstruction for diagnostic colonography that is symptom-driven. But for screening VC, the group has had better luck using the unlisted or "Not Otherwise Classified" code, Rolnick said.
"It's kind of a catchall for procedures that are not reimbursed, and it allows you to make a case-by-case (argument) for reimbursement," he said. Still, the reimbursement for unlisted codes is generally quite poor, and the tactic never works for Medicare, he said. So in that case, why shouldn't radiologists simply use the same CT abdomen, CT pelvis, and 3-D reconstruction codes for screening that they use for diagnostic VC?
"There are a couple reasons why I think it's better to use unlisted codes (for screening)," Rolnick said. "(If you don't), you may actually succeed in being reimbursed, but the payor may not understand that the exam is screening. And it can obviously lead to problems down the road if you're submitting all these claims for screening and mistakenly being reimbursed. The second point is that if you are billing (screening) patients a different amount from your charge for a (diagnostic) CT abdomen and pelvis, then you're using two different charges for the same CPT code, and that is actually a violation of Medicare policies."
Finally, the regular charges for CT abdomen and pelvis are usually quite high, over a thousand dollars, and more than most patients would want to pay if the claim were rejected. Therefore, providers who want to try to bill for screening VC would be advised to take their chances with the unlisted code, he said.
Failed colonoscopy
One way to bill for diagnostic VC is to perform it after conventional colonoscopy fails, Rolnick said. However, he cautioned that the appropriateness of virtual follow-up depends on why conventional colonoscopy failed in the first place. If screening colonoscopy could not be completed, the virtual follow-up would not be covered if the screening exam were considered diagnostic. If the conventional colonoscopy is not diagnostic, the virtual should be covered.
And if, during screening colonoscopy, the colonoscope were to encounter a mass that kept it from reaching the cecum, then even screening colonoscopy could be appropriately followed up with a diagnostic virtual colonoscopy exam, he said.
How much should we charge for VC?
"We asked this question as well when we...wanted to set our price for screening," Rolnick said. The group surveyed a number of VC providers, asking for the fee as well as the technical and professional components. "And our finding was that there's this huge range," he said.
Screening at freestanding centers tend to be clustered in the $700-$900 range, he said; most of the variability in pricing comes from the hospitals. Freestanding centers tend to be more market-sensitive, while hospitals have a more multifaceted approach to pricing, he said.
But Boston's Massachusetts General Hospital was a bargain at $500. And overall, the group found that the professional component of virtual colonoscopy charges typically runs between 20% and 35% of the total cost of the exam. Diagnostic VC generally costs between $1,100 and $1,400, Rolnick's group found.
The road ahead
"The path to reimbursement is going to depend on having additional screening data, and additional support from professional organizations," Rolnick said. "But there are some precedents for coverage of CT screening exams. There are CT bone density measurements that are covered as long as the patient has a family history of osteoporosis."
"I think that once we get over the coverage hurdle, the next battle will be over the level of reimbursement, because when Medicare sets its fee for the CPT code, if one is created for screening colonography, it will be based on what's currently being charged for the procedure," he said. "And whether hospitals and practices will view that as sufficient when it's being paid by insurance, well, it will be interesting to see if it's at a level that seems appropriate."
By Eric BarnesAuntMinnie.com staff writer
November 19, 2003
Copyright © 2003 AuntMinnie.com
