Tag: #MRI

Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Use of Imaging Studies for Low Back Pain

Posted on by KR2Medical Billing

HEDIS Measures get updated every year. In this post we will discuss the proper coding and billing for HEDIS Measure: Use of Imaging Studies for Lower Back Pain; and list the changes for the upcoming 2022 year. This measure applies to all types of insurances: Medicare, Commercial, and Medicaid.

Background:

One out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.  Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.

What causes back pain?

HEDIS Measure: Use of Imaging Studies for Low Back Pain Definition-
Members 18-50 years of age with a new primary diagnosis of low back pain in an outpatient or ED visit who did not have an x-ray, CT or MRI within 28 days of the primary diagnosis. A higher score indicates appropriate treatment of low back pain (i.e., the proportion for whom imaging studies did not occur)

Proper Medical Coding:

CPT codes for imaging Studies-

List of Proper DX codes:

Measure Exclusions:

Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.

Proper Exclusions Coding:

Improve the score for this HEDIS Measure:

-Avoid ordering diagnostic studies within 30 days of a diagnosis of new-onset back pain in the absence of red flags (e.g., cancer, recent trauma, neurologic impairment,
or IV drug abuse).
• Provide patient education on comfort measures, e.g., pain relief, stretching exercises, and activity level.
• Use correct exclusion codes if applicable (e.g., cancer).
• Look for other reason for visits for low back pain (e.g., depression, anxiety, narcotic dependency, psychosocial stressors, etc.).
• Document and code/bill all comorbidities (e.g. MVA, fall, trauma, etc.

HEDIS Measure: Use of Imaging Studies for Low Back Pain 2022 Changes:

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Posted in Insurance, Training, Updates

MVP Plans (NY) High Tech Radiology Policy Changes -2021

Posted on by KR2Medical Billing

As of January 1, 2021 the following MVP Plans will no longer require prior authorization for High Tech Radiology Services:

MVP Medicare Advantage Plans

MVP Medicaid Managed Care

MVP Harmonious Health Plan (HARP)

MVP Child Health Plus (CHP)

These services include: MRI/MRA, PET Scan, Nuclear Cardiology, CT/CTA, and 3D Rendering Imaging Services

This applies only to the services rendered by IN Network Providers. For any of the above mentioned plans that do have Out of Network benefits and would like to go to an out of network provider: the Prior Authorization is Required!

To request an authorization: please complete a Prior Approval Request Form (PARF) and fax it to MVP at 1-800-280- 7346.

ALL other MVP plans still require a prior authorization for HIGH Radiology Services. To request an Auth please contact eviCore Healthcare by submitting requests at evicore.com or by calling 1-800-568-0458.

#MRI, #MRA, #PET, #MVPCHP, #MVPHARP

Posted in Insurance, Payers and CPT reinbursement, Training, Updates

The Empire Plan (NYSHIP)- Prospective Procedure Review and Advance Imaging Procedure Programs Information-getting paid!

Posted on by KR2Medical Billing

The purpose of this post is to go over the needed information on when Prior Procedure Notification is required for The Empire Plan (NYSHIP) members.

According to The Empire Plan Prior Notification is required when The Empire Plan is the primary insurance NOT when it is secondary or tertiary.

The following list of Advance Outpatient Imaging Procedures require a Prior Notification:

1. CT- Computerized Tomography

2. MRI- Magnetic Resonance Imaging

3.MRA- Magnetic Resonance Angiography

4. Nuclear Medicine

5. Nuclear Cardiology

6. PET-Positron Emission Tomography

Q: Are there any exclusions to this?

A: Yes. If the services are performed in Inpatient setting*, Emergency Room, observational unit, or urgent care center they do not require a Prior Notification.

*Note: Inpatient services do not require PPR notification. However, hospital admission might. BCBS is responsible for mandatory pre-admission certification portion of (BMP) Benefits Management Program. This requires a call prior to any elective (scheduled) hospital admission that includes an overnight stay. If the patient is admitted into the hospital please call BCBS with 48 hours.

Q: Does outpatient surgery require a notification call?

A: No

Options for ordering a notification number:

1. Online- UHCprovider.com/Radiology- where providers can select to go to Prior Authorization and Notification APP.

2. Phone: Radiology Notification Line: 866-889-8054, M-F 7am to 7pm EST or

3. Phone: Empire Plan- 877-NYSHIP (877-769-7477) M-F 8:30am- 4:30pm

Q: What information will I need to request a Notification #?

A:  Information about Ordering provider and Rendering provider:

 1. Ordering provider: name, TIN./NPI, Address, Phone#, Fax# and Email

 2. Rendering Provider: name, TIN/NPI (if different), address, Phone#

In addition you need to include Clinical Information:

1. Working Diagnosis with appropriate ICD code(s)

2. Enrollee’s clinical information that should include symptoms, prior treatments, dosage and duration of any medications, plus dates of other therapies.

3. Examination(s) or type of services that are being requested with appropriate CPT code(s)

4. Any other information that ordering provider believes would be useful in evaluating the request.

Remember: in order to ensure that the proper payment is dispersed, the number should be obtained and communicated by the ordering physician/provider to the rendering physician/provider that is scheduled to perform the advanced outpatient imaging procedure(s).

Q: If the procedure was done outside the standard business hours and on urgent clinical basis, is there a retrospective review?

A: Yes. If the services were done outside of UHC normal business hours, the provider needs to contact the Radiology Notification Phone line within the 2 business days of the service(s). Also documentation must have an explanation why the procedure was required on an urgent basis and was done outside of UHC normal business hours.