Pre-authorization snag may require ABN.
If your practice performs MR urograms, you need to be prepared to handle a few reimbursement roadblocks.
You may find conflicting information in researching how to code MR urograms. For example, you may come across sources that say to report both abdominal and pelvic MRIs, but you’ll have to reconcile this advice with certain payers preauthorizing only an abdominal exam.
Protect yourself: The MR urogram issue reveals several questions that need to be addressed:
- What did the treating physician order?
- What did your facility perform and document?
- What did the insurance company authorize?
1. Insist on Orders for Both Exams
Be sure you have orders from the treating physician for both abdominal and pelvic MRI exams before you consider reporting both — for example, 74183 (Magnetic resonance [e.g., proton] imaging, abdomen; without contrast material[s], followed by with contrast material[s] and further sequences) and 72197 (Magnetic resonance [e.g., proton] imaging, pelvis; without contrast material[s], followed by contrast material[s] and further sequences) for exams performed without and with contrast.
Auditors will want to see precise orders, so you should not assume that an “MR urography” order refers to abdomen and pelvis. Don’t be tempted to think otherwise just because you can easily find support that physicians consider MR urography to include pelvis and abdomen studies. For instance, the American College of Radiology (ACR) “Appropriateness Criteria for Acute Onset Flank Pain,” refers to “MRI abdomen and pelvis with or without contrast (MR urography).” (To locate appropriateness criteria, go to www.acr.org. Choose the “Quality and Safety Resources” link. Then click on the “ACR Appropriateness Criteria” link.) But for your records, precise orders will offer your claim the most support.
2. Demand Distinct Documentation
To support reporting both abdomen and pelvis MRIs, also be sure the radiologist has documented both exams clearly. Ideally, the radiologist will record each in a separate paragraph, describing the organs visualized and pertinent comments and findings. For example, the abdominal MRI documentation might focus on the kidneys and urinary collecting system for anatomical or physiological abnormalities. The pelvic documentation might assess any pelvic floor defects associated with urinary incontinence.
Resource: The ACR provides online practice guidelines for pelvic and abdominal MRIs:
- Abdomen: www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/gastro/mri_abdomen.aspx
- Pelvis: www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/gastro/mri_pelvis.aspx.
3. Assess Need for ABN
If the insurer preauthorizes only an abdominal MRI, then expect the insurer to reimburse only the abdominal MRI. The treating physician still may determine that both pelvic and abdominal MRI exams are necessary for the patient. In that case, alert the patient that he may be financially responsible for the pelvic MRI. Have him read and sign a waiver or Advance Beneficiary Notice (ABN) agreeing to cover the cost if he chooses to have the exam. For Medicare, append modifier GA (Waiver of liability statement issued as required by payer policy) to the pelvic MRI code to indicate you have an ABN on file.
ABN alert: Remember that CMS updated ABN modifiers effective April 1 (www.cms.hhs.gov/MLNMattersArticles/downloads/MM6563.pdf). Modifier GA changes from “Waiver of liability statement on file,” which simply indicated that you have a signed ABN on file, says Melinda Brown, CMBS, insurance biller with H. Matt Smith, MD, in Kennewick, Wash. The new descriptor is “Waiver of liability statement issued as required by payer policy.” You should use modifier GA only “to report when a required ABN was issued for a service,” CMS states. Modifier GA indicates the possibility that Medicare may deny a service for medical necessity, and the physician may bill the patient after the claim is denied.
New modifier GX (Notice of liability issued, voluntary under payer policy) shows you provided “beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute,” CMS states.
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