Adding new technology can help bring in new customers and additional revenue. But if you don't move carefully, it can also cause major headaches and unanticipated problems.
When Moncrief Cancer Center in Fort Worth, TX, decided to add PET/CT, it began by setting up a task force that meets weekly to discuss the project, according to Ed Townley, the manager of patient financial services.
The group, led by the center's information technology director, considered several points before it began, Townley said.
- The need: Will the area and referral base support the new technology?
- The physical site: Where could the machine be located, and could it fit all the necessary components?
- Reimbursement: Will carriers pay for the new services, and when will they pay?
- Referrals: Will physicians be willing to refer patients to you, and how will you educate the physicians about the new technology?
Making the decision
The first step toward adding a PET/CT program involves determining whether you have the patient volume to support one. Consider the following:
- Are you planning to tap into an existing referral base?
- Will it be enough to get you off the ground?
Finding the answers to these questions is critical, Townley said. Also, consider your competition -- or potential competition.
"Keep in mind that you will have competition," he said. "It's only just a matter of when."
Then ask yourself the following questions:
- Do I have an existing referral base for diagnostic scans and oncological applications, or will I be primarily oncology-related? (Moncrief falls into the latter category.)
- Will I conduct many diagnostic scans with oncology as a second market?
- Am I building strictly for-profit modes? Proceed carefully if that is what you are doing, Townley said.
Moving ahead
After you decide to go ahead with the process to add PET/CT, consider the physical site. Make sure it meets your needs:
- Can it accommodate a hot lab?
- Does it have adequate storage?
- Will it have separate bathrooms and waiting areas for patients to use after they receive the radioactive infusion?
Plan ahead, because making changes later on is not easy if you find the site is insufficient, Townley said.
Reimbursement and contracts
It's also important to plan ahead when it comes to billing to ensure that you can collect on your investment. Examine your contracts and verify that they will allow you to add new services in the middle of a contract period.
Moncrief had many contracts that were a mix of annual and two-year agreements. Most pacts allowed for adding the new services as an addendum, but others were insistent that new services not be added until the end of the contract period, when it was up for negotiation, Townley said.
Hammering out codes
Moncrief also had to negotiate with carriers over what codes they would accept.
"We had some carriers that were not enthusiastic about adding G-codes," Townley said. "They weren't interested in HCPCS (Healthcare Common Procedure Coding System) codes at all."
At that time there was only one code for PET: CPT code 78810.
However, other carriers were interested in the HCPCS codes because they provided a higher level of specificity, Townley recalled. Once some of the carriers understood the level of specificity, they approved the use of the G-codes.
Since Moncrief began its PET/CT program, current procedural terminology (CPT) codes have been added for use with PET (although the timeline for use of these codes is still uncertain).
"We're trying to ensure that (the payors will) accept the new CPT codes, and we're still in negotiations with them about that," Townley said.
Because different carriers have different preferences, it was critical for Moncrief to set up billing systems that recognized those differences, he said. For example, one carrier wanted them to use CPT code 78810, which did not include the cost for FDG. That was an additional cost, according to the billing codes. Other carriers, however, allowed them to use the G-code, which included the FDG dose.
"We had to set up our procedures a little bit differently to flag that FDG dose as a separate line item on the charge," Townley said.
Also, be proactive when working with Medicare, he said.
"If you have a new technology coming, get in touch with your local Medicare carrier to let it know its coming and discuss it. If they understand the technology, they are less likely to deny first and pay on appeal," Townley explained.
Be certain to set time limits
Even though Moncrief's coding issues were settled, the problems didn't end, Townley said. Some carriers neither had the codes to existing contracts nor made them billable by the time the PET/CT machine was ready for use. The contracts failed to specify a timeline for this process, which left Moncrief at the mercy of the carriers.
The center was open and had fixed expenses, he said, but it could only take patients with certain carriers.
Fortunately for Moncrief, the physicians who were referring patients for the new PET/CT scans understood the problem and helped by sending patients who could be processed, Townley said. There were times when patients had to be rescheduled because of delays in precertification, but they tried to avoid this whenever possible.
To avoid problems with carriers, make changes to your contracts now to ensure that you can add technology in the future, Townley advised. Specifically, add a paragraph in your contracts that limits the length of time a carrier has from when the contract is signed to when all codes are uploaded into the system and approved for billing (30 days, for example), he said. Also be certain that the contract explicitly states that those same time limits apply to any outside precertification firm the carrier uses.
Troubleshooting after startup
Once your PET/CT operation is up and running, set up a plan to flag diagnoses that could pose a billing problem, as well as those that will require additional supporting documentation. Townley has written up checklists for areas that Medicare is particular about to ensure that all necessary information is collected to support reimbursement requests.
"We have a state Medicaid carrier that will not pay for PET or PET/CT under any circumstances," Townley said. Some versions of TRICARE (U.S. military health system) will also deny reimbursement for these scans, he added. "You need to let your scheduler know which (insurance) carriers are problematic (so that they can) let you know when a patient with one of these carriers is in the pipeline."
In addition to taking steps to ensure that the performed procedures will be covered, decide ahead of time what you will do if something is not covered, Townley said.
Structuring your department
It's a good idea to separate employees handling scheduling and precertification. It is too difficult to have the scheduler handle precertifications, Townley said. He or she probably won't have time to sit on the phone and wait for an answer on a case.
Also, ensure that appropriate staff members review appointments to prevent denials, he said.
"At our facility, the reading radiologist reviews for medical necessity and makes certain the scan will give the referring physician the information he or she needs," Townley said.
A coder also looks at the information to assign the proper diagnosis and procedure codes.
Having both the radiologist and coder review the information at the same time can flag potential problem areas, such as whether additional pathology or clinical information is needed to justify the scan.
"We do a lot of work on the front end and, as a result, we've never had a denial in a year or more of operation," Townley said.
Medicare now conducts postpayment reviews with PET scans. This means you must collect all the documents you need to substantiate medical necessity at the time of the exam, said Stacie Buck, president of Health Information Management Associates in North Palm Beach, FL.
Trying to get that information later will prove problematic, she predicted. When you receive this information, keep it accessible with other medical records for the patient, she said. Having a documentation checklist is also helpful in this process.
Be certain to re-evaluate periodically
Although it's important to establish solid systems up front, remain flexible.
"Whatever process you put in place out in the trenches, you will find that it changes," Townley said. "If you have any process or procedure in place at the beginning of your program, don't think it will be equally valid eight months or a year down the line. My suggestion would be to re-evaluate regularly. Come back after three months and examine everything from the top down."
By Ed Townley and Stacie Buck
AuntMinnie.com contributing writers
September 2, 2005
This article originally appeared in the Radiology Administrator's Compliance & Reimbursement Insider, a monthly newsletter published by HCPro that is designed specifically for radiology administrators.
Townley and Buck spoke during a recent audio conference, "PET/CT: Strategies for setting up an effective program," sponsored by HCPro. To order a copy of the tape, call 800-650-6787.
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PET/CT planning allows for greater gamble on NSCLC radiotherapy, March 16, 2005
PET/CT demonstrates staging strength over PET, CT, and PET plus CT, March 7, 2005
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