What Constitutes a Session?
"I know it when I see it." The phrase became famous in 1964, when U.S. Supreme Court Justice Potter Stewart used it to describe his threshold test for obscenity in Jacobellis v. Ohio.
Having the same level of certainty about what constitutes a session is going to be challenging for radiologists and their business managers as practices try to comply with the proposed CMS rule for 2013 that applies a multiple procedure payment reduction (MPPR) not just to examinations performed by the same physician but also to procedures performed within group practices.
The language in both the final rule for 2012 and the proposed rule for 2013 is vague, and the recommendation that practices use the -59 modifier to indicate that services have been provided on the same date of service but not in the same session is fraught with difficulty.
For example, imagine a scenario in which one radiologist interprets a head CT in the emergency department at 8 a.m. Ten hours later, the patient has mental status deterioration suggesting intracranial hemorrhage and undergoes a second head CT, which is interpreted by a second radiologist in the group. Is that one session or two? Since there is a significant lapse in time, the ACR would consider this a separate session. (CMS would see it the same way, presumably, based on the guidance we have currently.) But if two exams — a head CT and a cervical spine — are performed one immediately after the other, and each is read by two different radiologists, the exams are performed in the same session according to our interpretation of the CMS' guidelines, although we steadfastly maintain that there are no efficiencies in this scenario that would justify reducing the professional component payment for the second service.
From a billing and coding point of view, this lack of guidance presents a number of difficulties. A coder working from a single report has, in most practices, no way of knowing for sure that other examination was interpreted by a separate radiologist in the group in a separate session. The failure to apply the -59 modifier to the second procedure will result in an inappropriately reduced reimbursement for that examination. Even a coder who remembers coding a report on this patient for the same date of service would, in most practice scenarios, not have any information as to the times of the examinations, as time-stamp data from the PACS system is rarely, to our knowledge, transmitted into the dictated report that the coder uses to make his determination. This means that the -59 modifier could be inappropriately applied by a coder who believed that two different examinations constituted separate sessions, leaving the practice at risk in an audit.
The -59 modifier is used in a number of circumstances, including when bypassing a correct coding initiative (CCI) edit. Could use of this modifier to appropriately bypass a CCI edit be construed as an attempt to bypass the MPPR? From the CMS point of view, there is really no way to know the intention of the coder applying the modifier, which may lead to confusion as to why the modifier was applied.
In speaking with experts from the RBMA, it is evident that even when a clarified definition of a session, significant modifications would have to be made to most billing systems to capture the examination information in a way that would permit coders to even attempt to correctly apply the modifiers. Some have expressed doubt that it is possible at all.
All of the above will lead to sleepless nights for both radiologists and their business managers. We have all heard horror stories about the burdens placed on practices by misguided audits by recovery audit contractors. With margins slimmer than ever due to progressive reimbursement cuts, the cash flow implications of these audits are magnified. The lack of clarity around the definition of a session, added to a policy that is inherently flawed, is the last thing radiologists need as we attempt to deliver the highest quality imaging to our patients.
The ACR has engaged CMS to express our concerns both in a face-to-face meeting as well as with our strongly worded comment letter on the 2013 Proposed Rule. We have stressed our fundamental disagreement with the CMS assumption that meaningful efficiencies exist when one physician interprets two examinations on the same patient or when those same examinations are interpreted by different physicians. We have also detailed the difficulties practices already face in implementing the MPPR for the professional component for individual physicians and the additional complexity and compliance risk that the proposed group practice MPPR imposes. We hope for a reasoned response when CMS issues the 2013 final rule next month. If that's not the case, look forward to a call for action.
By Geraldine B. McGinty, MD, MBA, Chair