Radiology Coding Alert

Follow these examples when the lines of correct diagnostic coding begin to blur.

A good radiology coder strives for accuracy, specificity, and precision when reviewing each and every dictation report. For most, it’s second-nature to incorporate every component of the impression with its correlated diagnosis code. A lesser-discussed problem within the field of radiology coding, however, is the idea of diagnostic upcoding and downcoding. As general concepts, these two are notoriously frowned upon, but these terms are less understood as they apply to diagnosis coding.

Upcoding and downcoding are usually thought of from an E/M perspective. When an E/M visit is billed as more or less comprehensive than it actually was, you are guilty of upcoding and downcoding, respectively. The same rules apply for CPT^® procedures. For instance, submitting a complete abdominal X-ray when no definitive number of views is documented would be an example of procedural upcoding. Unfortunately, the discussion over upcoding and downcoding generally ends there.

But there’s another side to this story. And even those familiar with diagnostic upcoding and downcoding don’t understand the full extent of the situation. As it applies to diagnosis coding, upcoding and downcoding can be understood from a quality and a quantity perspective: Quality as it relates to the specificity of the code at hand and quantity as it relates to the number of codes attached to a particular CPT^® code.  Ultimately, however, a coder’s ability to correctly assign a diagnosis code is left at the mercy of the physician’s dictation reporting.

Just the right amount of specificity

Ambiguity within a dictation report is one of the most fundamental problems radiology coders face. The general rule is to opt for the unspecified diagnosis code when the wording does not definitively match the more specified code’s description. This becomes increasingly difficult as the number of characters within a diagnosis code increases. It’s for this reason that some coders find neoplasm and fracture coding so difficult.

There are a few scenarios, in particular, that coders should be especially weary of when it comes to ambiguity. “Uncertain diagnoses indicated by words such as ‘probable,’ ‘suspected,’ or ‘rule out’ should never be coded, yet we see these reported inappropriately for outpatient care,” relays Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York. “Additionally, coexisting conditions and historical conditions should only be reported if they are related to the current management and treatment of the patient.”

Let’s examine a few examples of how a particular diagnosis might end up being unintentionally downcoded or upcoded:

Diagnosis: Malignant neoplasm right female breast, 1 o’clock

You might come across some providers that pinpoint neoplasms of the breast using the “clock hand” method. Since ICD-10 doesn’t incorporate this terminology into the code set, your initial response might be to revert toward the unspecified code C50.911 (Malignant neoplasm of unspecified site of right female breast). However, this would be an example of diagnostic downcoding.

Since you know that breast malignancies are separated by quadrant, your next step is to determine in which quadrant the 1 o’clock hand lies in. Unfortunately, the anatomical diagram in your ICD-10 manual does not elaborate on quadrant specificity. But a simple Google search will reveal numerous illustrations outlining the specific quadrant for each clock hand.

You will see that 1 o’clock correlates to the upper inner quadrant of the right breast. The correct diagnosis code is C50.211 (Malignant neoplasm of upper-inner quadrant of right female breast).

Diagnosis: Right achilles tendinopathy

A common response to a diagnosis of tendinopathy is to code for tendinitis. In this case, you might instinctively be drawn towards M76.61 (Achilles tendinitis, right leg). But this would be an example of upcoding for numerous reasons. First, “tendinopathy” is not a searchable term within the ICD-10 index. Second, the term “tendinopathy” is a relatively general term describing disease of the tendon. Since a search for Disease à muscle/tendon also leads you nowhere, your only option is to code as M67.971 (Unspecified disorder of synovium and tendon, right ankle and foot).

The Medical Necessity Factor

One of the most common misconceptions in the coding industry is the idea that a procedure is universally best suited with the maximum number of diagnosis codes attached. Depending on the way you look at it, there might be some degree of validity to this statement. However, context plays an integral factor when determining which diagnoses are appropriate for a particular procedure code. It is important to understand that a radiologist might include diagnoses in the impression that are not necessarily relevant to the patient’s presenting problem(s). “The responsibility of the radiologist is to report any relevant findings,” explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “Whether they are directly related to the acute presentation or not, they still may be medically relevant.”

A fundamental part of radiology coding involves the ability to discern between those “generally” relevant diagnoses in the impression from those diagnoses that are related to the reason the patient patient is presenting for imaging in the first place. An inability to pick out the correct diagnoses from the impression can lead a coder to commit another form of upcoding and downcoding.

For example: If you apply too few relevant diagnoses to a certain procedure code, you would be committing a second version of diagnostic downcoding. The idea is the same in respect to the overapplication of diagnosis codes to a procedure code. You will determine the correct diagnoses to apply by examining which elements of the impression are and are not medically relevant as they relate to the procedure at hand. Here’s an example documenting how both downcoding and upcoding scenarios might unfold:

Procedure: CT Abdomen/Pelvis w/o contrast

Indication: Lower abdominal pain, hypertension, dysuria

Findings: Calculus gallbladder, fatty liver, calculus kidney, hydronephrosis

Impression: Calculus kidney, hydronephrosis, calculus gallbladder

Some coders might argue that the answer to this question is subjective. If there is additional context surrounding these diagnoses, it may be. If the dictation report is as clear-cut as the example above, however, the correct diagnoses should always be the same.

One common belief in the field of radiology coding is that, if the physician references a disorder or disease in the impression, you should automatically code it. However, that is not always the case.

Based on the procedure and the dictation report, there are three routes you can take in this scenario.

First, you could opt to downcode by billing out with too few diagnoses. For example, if you apply the single diagnosis of N20.0 (Calculus of kidney), you disregard one additional, pertinent diagnosis.

On the other hand, if you include K80.20 (Calculus of gallbladder without cholecystitis without obstruction), K76.0 (Fatty [change of] liver, not elsewhere classified), and N13.30 (Unspecified hydronephrosis) in addition to N20.0, you’re upoding.

The correct diagnosis codes to apply to 74176 (Computed tomography, abdomen and pelvis; without contrast material) are N20.0 and N13.30.

Explanation: You can find the answer to this problem by addressing the question of relevancy. Which diagnosis codes are relevant to both the procedure and the reason for admission? While findings not included in the impression cannot automatically be ruled out, the general rule of thumb is that if a finding is not included in the impression, it is most often considered an incidental finding.

In this case, fatty liver is not relevant to the primary indicating diagnoses of lower abdominal pain and dysuria. Similarly, while calculus of the gallbladder is referenced in the impression, the anatomical location of concern is within the genitourinary tract and lower abdominal area.

The answer to this question is ultimately left up to your discretion. However, it’s important to keep in mind why the patient is presenting for imaging in the first place. Unless the provider specifically states that a nonrelated finding requires follow-up imaging, it should not be included as a related diagnosis code.