Radiology Coding Alert

Learn little-known rules that help with documentation curveballs.

Your dream documentation might word every diagnosis to perfectly match an ICD-9 code descriptor. But the reality is that sometimes you have to struggle with too little information on the order or too much information in the findings. 

What to do: "Part I: Prove Dx Test Necessity Using 3 CMS-Approved Strategies" in Radiology Coding Alert, Vol. 12, No. 2, presented three key tactics for properly coding diagnostic exams:

1. Base your ICD-9 code on a confirmed diagnosis whenever possible.

2. Choose a "signs and symptoms" code for "normal" tests.

3. Fight the urge to choose a diagnosis based on "uncertain" terms, such as "rule out."

Now check out two final strategies to apply when your documentation doesn't offer obvious answers.

1. Take Patient's Word for It ... Rarely

At some point, you may hit a snag because the treating physician doesn't offer your practice sufficient information. For example, suppose a treating physician does not  supply a reason for a test, and the radiologist documents normal results. In this case, "it is appropriate to obtain the information directly from the patient or the patient's medical record, if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the ordering physician," states Medicare Claims Processing Manual (MCPM), Chapter 23, Section 10.1.2.A (www.cms.hhs.gov/Manuals/IOM/list.asp).

Example: A physician orders a test for a patient without documenting a reason. The test is normal. The patient explains that she is suffering from intense pain in her lower right abdomen, and the treating physician wants to rule out appendicitis. You should report the appropriate pain code in this case, such as 789.03 (Abdominal pain; right lower quadrant).

Tip: In the rare case that you obtain the information from either the patient's chart or from the patient, the provider must document the source of this information "as part of the history within the radiology report (i.e., 'Patient states...')," says radiology coding consultant Cheryl A. Schad, BA Ed, CPC, ACS-RA, PCS, of Schad Medical Management in New Jersey in her audio seminar "Radiology Documentation and Ordering Rules" (www.audioeducator.com). Otherwise, an insurance auditor may assume that because the information was not on the order, your practice "created" the diagnosis for payment purposes, she warns.

2. Avoid Incidental Findings Trap

Radiologists must be thorough in their interpretations, commenting on the abnormalities they see in the views taken. As a result, radiologists often will document incidental findings -- meaning diagnoses unrelated to the reason for the test. You should never report incidental findings as primary diagnoses, instructs section 10.1.3.

CMS and ICD-9 guidelines state that you may report incidental findings as secondary diagnoses. But Schad warns that listing incidental findings may increase your denial risk because the incidental finding may not support medical necessity for the coded exam.

Example: A physician orders a chest X-ray for a patient because of wheezing. The X-ray is normal except for scoliosis (such as 737.3x, Kyphoscoliosis and scoliosis ...) and arthritis of the thoracic spine (such as 721.2, Thoracic spondylosis without myelopathy).

The correct primary diagnosis code would be wheezing, says Alice E. Wonderchek, CPC, billing and coding specialist with Franklin & Seidelmann Subspecialty Radiology in Beachwood, Ohio. So you should report 786.07 (Wheezing), she says. Technically, you may add scoliosis and arthritis as secondary diagnoses, but this will not support medical necessity for a chest X-ray.