Jeyaram & Associates - Client Advisory

Make Sure You Get Paid for Outpatient Radiology

By DJ Jeyaram

On September 1, 2005, the Georgia Department of Community Health began implementing a legislative mandate requiring prior authorization (“PA”) for certain types of high-cost radiology procedures performed in ANY outpatient settings, including free standing radiology centers, ambulatory surgery centers, outpatient hospitals and physician offices. PA will not be required for tests performed for inpatients.
Prior Authorization will be required for imaging procedure codes in the areas of Obstetrical Ultrasound, PET Scans (Brain and Whole Body), CT Scans (Head and Pelvis/Abdomen), and MRI (Brain and Lumbar Spine), a full list is at the end of this article. The Web-based request entry process is similar to all other PA Web submissions currently in use by Georgia Medicaid Providers.

In urgent or emergent situations, Providers will have thirty (30) days from the test date to request a prior authorization. If the case starts out in the Emergency Room and then the patient is admitted as an inpatient, the radiology test(s) do not need prior authorization. But be careful! The inpatient hospital stay may require review according to DCH Hospital Services Manual requirements. The inpatient hospital request must be submitted using the Hospital Admission and Outpatient Procedures PA request and not the Radiology PA type request.

Also be careful to distinguish between “inpatient” status and “observation” status admissions. If admitted under “observation” status, the provider will still need to get PA for radiology tests. Providers may want to see if the patient is admitted before requesting a radiology prior authorization, because imaging codes do not need to be submitted as part of an inpatient hospital stay.

There is some concern among providers regarding who is responsible for obtaining the radiology PA, checking medical necessity and providing clinical information to GMCF. As with other categories of PA, physicians shall be responsible for providing all this information and obtaining the PA. The Department plans to change its Physician’s Service Manual in October of 2005 to state: "The ordering physician is responsible for obtaining the Prior Approval. The physician's failure to obtain Prior Approval will result in denial of payment to all providers billing for services including the facility. If the info submitted for the PA is incorrect, then both would be denied. Hospitals and physicians are both able to search the GMCF database on the internet to see if prior approval has been obtained for a particular patient and test. However, note that although the ordering or attending physician is responsible, facilities MAY request PA if they have the clinical information available. In some cases, outpatient clinics or hospitals serve this function for physician groups based upon their business arrangements.

Once PA is requested, the Department’s nurse reviewers will utilize InterQual criteria and Department of Community Health (DCH) policy guidelines to review Radiology PA requests. If the request meets InterQual criteria and DCH policy guidelines, the nurse will approve the case. If the case is not approved, the Provider may submit additional information for reconsideration. The reviwer will have up to seven (7) days to provide an authorization. Upon reconsideration, the PA is either approved or denied. If denied, the provider will be notified of any appeal rights.

Denials most often occur when the nurse reviewer does not get a clear clinical picture of the patient’s medical condition and why the test was needed. When submitting requests, err on the side of submitting more information and be sure to include information on co-morbidities; Member’s age; complications; previous testing results and any physician interventions such as medication or surgery.

If a request is approved for a particular radiology code, but once the procedure begins, the technician determines that a different procedure needs to be performed, providers have 30 days from the date of service to request changes (including procedure code changes). Be warned that the provider will still need to provide sufficient documentation that the new test is medically necessary.

Neither the hospital/facility or the physician may bill its claim until the PA is obtained. Even though the onus is on the physician to obtain the PA, it is likely that if one claim gets denied both parties’ claims will be denied even if one party is not at fault. Therefore, it is important for both parties to check on the GMCF website that PA has been obtained or risk the possibility that the claim will be denied by the Department.

CPT Codes Requiring PA as of September 1, 2005 (subject to change).

For more information, contact us at 404.995.6792 or at dj@jeylaw.com.
This article is presented for educational and informational purposes only and is not intended to constitute legal advice.

About the Author

Deepak (“D.J.”) Jeyaram is the founder of Jeyaram & Associates, a full service health law firm. He represents a wide variety of healthcare providers including hospitals, nursing homes and physician group practices. He concentrates his practice in healthcare regulatory matters, primarily in administrative appeals and Medicare and Medicaid reimbursement.

His prior experience includes working in-house with Georgia Medicaid, rising to the position of Deputy Director of Legal Services. Later in his career, Jeyaram was an Administrative Law Judge who presided over disputes between the Georgia Department of Community Health and Medicaid providers on issues involving reimbursement, utilization review and provider termination. Jeyaram received his bachelor’s degree, cum laude, from Boston University and his law degree from Emory University.

Jeyaram & Associates is conveniently located in the heart of Buckhead in the Pinnacle building next to Lenox Mall. For a map of the office location, please click here.

For a free consultation, call DJ Jeyaram at 404.995.6792 or send an email to dj@jeylaw.com.