5 of the Best Diagnostic Radiology Coding Tips

How effective are your practice's coding procedures and policies?  In financial terms, medical coding is the life blood of the practice.  It's how the services you provide turn into billable revenue.  Failure to code correctly can lead to a myriad of problems including delays or lack of reimbursement and even fraud.  There are active steps you can take to improve medical coding and maintain a healthy bottom line.  Here are a few tips that are not only recommended by our team, but are also very popular among other radiology billing organizations and billing thought leaders! 

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The 3 C's of Documentation for Radiologists

To promote improved coding and billing, it’s good practice for radiologists to remember the three C’s of reporting and documentation: clarity, consistency and care.  This is something that the coding department, billing department and radiologists should ALL focus on, since some of the most common radiology coding errors – those related to eligibility, referrals, and dictation error – involve all groups.

Dictated reports should be concise, clear, and should meet ACR guidelines by containing the following: 

  • Heading
  • Number of views or sequences
  • Clinical indications
  • Findings
  • Impression/Conclusion
  • Physician signature
  • Diagnostic studies

      Clinical indications, the performed exam, impressions and findings should all be clearly identified.  Here are a few more tips for better reporting:
  •  Report succintly with the referring physician in mind - Leonard Berlin, MD, FACR, radiologist at Skokie Hospital wrote for ACR Bulletin, “Our primary audience is referring physicians who have limited time, so our reports must get to the point and be organized to ensure referring physicians can find the information they need quickly and easily and refer to it again, as needed.”
  • Exam titles should include modality, views, anatomical site, and if contrast was used.
  • Make sure that exam titles aren't listed in the findings or impression sections.
  • Form an actionable impression to make the report more conclusive and encourage an accurate and timely diagnosis.

      Only Report Documented Views

      The number of views claimed must meet the basic requirements of the CPT code reported.  The medical report should include the number of views and it’s the coder’s responsibility to count the number of views and select the corresponding CPT code.

      If the physician includes view location instead of view number, that is an acceptable form of documentation.  The AAPC provides a great example of this: For a 73564 Radiologic examination of the knee with 4 or more views, the documentation must substantiate the number of views.  If instead of listing “4 views,” the physician states, “AP, lateral, and both obliques,” that is acceptable.  However, if the physician states, “multiple views of the knee,” the coder must report the lowest-level corresponding CPT code for that service.

      If your department has a list of “standard views,” coders must proceed with caution when using them.  For example, if a referring physician doesn’t include the number of views in the order, the coders can’t impose their standard views.  The radiology department should instead contact the referring physician and request a new order that includes the number of views that the referring physician would like performed.

      Complete Documentation for a Complete Exam

      For all “complete” studies, there must be complete documentation supported for that study.  Otherwise, coders must code down to the limited exam.  For example, if a complete abdominal study is completed, then there should be documentation for all of the following: liver, gallbladder, common bile duct, pancreas, spleen, kidney, upper abdominal aorta, and inferior vena cava.

      Implement New 2019 Codes

      For the year 2019, CMS has expanded the number of codes available in efforts to help radiology practices obtain payment easier for new services.  There are two new contrast-enhanced ultrasound codes, one new MR elastography code, and three new ultrasound elastography codes: 

  • 760X0X - Ultrasound, targeted dynamic microbubble sonographic contrast characterization (noncardiac); initial lesion - A stand-alone procedure for the evaluation of a single target lesion.
  • 76X1X - Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection – An add-on code for the evaluation of each additional lesion.
  • 76X01 - Evaluation of organ parenchymal pathology
  • 767X2 - First target lesion
  • 767X3 - Each additional target lesion 

  • *Some of these codes may be unavailable until Q2, please refer to CMS documentation provided here

    Include Proper Modifiers

    One of the biggest issues in radiology when it comes to coding-specific lost reimbursement is wrong modifiers used or no modifier being used at all when required.  Coders should refer to the National Correct Coding Initiative (NCCI) to determine if modifiers are necessary.  CMS created the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.  The CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.

    Radiology procedures include both professional and technical components, represented by modifier 26 and modifier TC, respectively. The professional component (Modifier 26) of a diagnostic service or procedure should be appended to a procedure code when only the professional service was rendered and is provided by the physician.  This may include supervision, interpretation, and a written report.  The technical component (Modifier TC) of a diagnostic service or procedure should be appended when only the technical service was rendered and represents the equipment, supplies, and clinical staff.  Payment for the technical component also includes the practice expense and the malpractice expense.  

    Both modifiers should be reported in the first modifier position on the claim.  If the same provider is performing both components, the “global” service should be reported, and no modifiers are necessary to receive payment for both components.

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