CODING CORNER: How To Steer Clear of These Radiology Coding Dangers

Bonus: Smart strategies to keep your claims audit-proof

The radiology department brings in a sizable chunk of your facility’s outpatient revenue, so if those claims aren’t clean, your reimbursement--and compliance--could be suffering. Take a look at these common problems with radiology reporting to find out how to make your claims defensible during an audit.
Danger #1: No Medical Necessity
If the diagnosis code you assign to the patient undergoing the radiological exam doesn’t provide a solid reason for the hospital to perform the study, you’ll be out of luck when you submit your claim.
Medical necessity can consist of the following, says Cheryl Schad, BA, CMC, CPC, owner of Schad Medical Management in Mullica Hill, N.J.:

• a conclusive diagnosis from the radiologist as a result of the diagnostic test

• a follow-up exam to confirm a medical condition (which should be documented in the history or clinical indication of the request)

• signs and symptoms.
Having well-documented medical necessity is especially crucial during an audit. The documentation should back up every code you reported, because “you do not want an auditor to come in and start rifling through all of your files to find the medical necessity for a particular study,” Schad says. “I guarantee that if they are going to go through your chart, they are going to find other things that you did not even intend for them to look at--so that is why you don’t want to have them scurrying through.”
Danger #2: Chargemaster Overrides
Be careful if you rely on chargemasters to do your coding, because many programs don’t allow you to select every CPT code in the book, Schad says. This flaw in the system may leave your claim with a code for similar--but incorrect--services.
Charge description masters (CDMs) sometimes have a function that defaults to the highest CPT code within a code family for certain procedures. With radiology codes, “that’s not going to work, because every single x-ray that is ordered is not going to be the highest-valued code within the family,” Schad says.
For example, if the radiographer only performed one x-ray view of the patient’s chest, you need to have the option to charge for just one view--your CDM or order-entry screens shouldn’t automatically force you to start off with a two-view study.
Idea: Some facilities are assigning the responsibility for maintaining these defaults and sequencing of procedures to the coding staff or claim scrubber software.
Danger #3: Omission of 76 and 77
Physicians often take multiple x-rays that reflect different views of the same anatomic area to get a better idea of the patient’s condition. For example, if a patient [...]

- Published on 2006-01-01