Radiology Coding Alert

Don't let these coding errors sink your claims

You assigned the correct CPT Codes and appended all of the required modifiers, but the carrier still denied your claim. You may be a victim of some common diagnosis coding myths that made you assign incorrect ICD-9 Codes to your claim.
 
The following radiology coding scenarios will show you how to tighten up your diagnosis coding to guarantee quick reimbursement.

Myth #1: Once you precertify, you can't add diagnoses. You precertified a surgery based on one diagnosis, but after the radiologist started the procedure he discovered other problems requiring surgical attention. Because you precertified only the original diagnosis, you can't report the additional procedures, right?
 
Not so fast. You can either precertify a code range or submit the follow-up diagnoses after the fact, says Elisabeth P. Fulton, CPC, a coding and auditing department supervisor in Winston-Salem, N.C.
 
Suppose the radiologist preapproves thoracentesis (32000, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for a patient with pleural effusion (511.9). After the radiologist begins the procedure, he aspirates a small amount of blood and pus from the patient's lung, which means that the patient actually has hemothorax (511.8). The radiologist inserts a chest tube and performs thoracostomy to remove the fluid (32020, Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]). Because the insurer only preauthorized the procedure based on the pleural effusion diagnosis, should the practice report both conditions?
 
Yes, but you can avoid this challenge if you precertify a code range rather than just one code, Fulton says. "Before the surgery, tell the insurer's precertification department that the surgeon may perform other procedures if he discovers additional diagnoses," she says. "We tell the insurance company's precertification department that the surgeon may very well perform more than one procedure, depending on what he discovers when he gets in and looks around."

Insurers rarely ask physicians to precertify just one CPT and diagnosis code. In rare cases, however, the insurer might ask you to simply precertify the intended procedure based on the confirmed diagnosis. In this case, you should precertify 32000, but you should reiterate that it is completely possible that you may perform and report more procedures if medically necessary.
 
If, after the surgery, the insurance company balks at paying for the thoracostomy, the interventional radiologist should write an appeal letter citing the date his practice requested preapproval, the fact that the practice attempted to precertify a code range, and the fact that he diagnosed hemothorax during the thoracentesis.

Myth #2: You can no longer report signs and symptoms as primary diagnoses. CMS' 2002 program memorandum AB-01-144 stated that if a physician confirms a diagnosis, he should report that diagnosis instead of the signs or symptoms that prompted the procedure. The key word in that sentence is "if," because if the radiologist doesn't confirm a diagnosis, you should still report the signs and symptoms.
 
Suppose another physician diagnoses your patient's husband with tuberculosis and you perform a chest x-ray (71020, Radiologic examination, chest, two views, frontal and lateral) to determine if your patient also has TB. Your radiologist documents "rule out tuberculosis" in his chart. ICD-9 coding guidelines state that you should not report "rule out" diagnoses, but you can still assign other symptoms, such as "cough" (786.2), if documented, and V01.1 (Contact with or exposure to communicable diseases; tuberculosis) to describe the patient's symptoms in the absence of a TB diagnosis.
 
Or, if you determine that a patient who fell from a ladder at work did not have a wrist fracture as you suspected, you should report any documented symptoms, such as wrist pain, as the primary diagnosis (719.43, Pain in joint; forearm), with E881.0 (Fall on or from ladders or scaffolding; fall from ladder) as a secondary diagnosis to describe how the injury occurred, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.
 
Whether or not the physician determines a definitive diagnosis, you are not precluded from reporting both the signs and symptoms as well as the definitive diagnosis that is found during the study. Rather than delete the initial predisposing signs and symptoms, you should report both the definitive diagnoses and the signs and symptoms that necessitated the testing.

Myth #3: Fudging that fifth digit is OK. If you perform an abdominal MRA on a patient with secondary hypertension (405.x), most carriers will only reimburse you if you specify that the patient had renovascular hypertension (405.01, 405.11, 405.91). Because Medicare coverage of abdominal MRAs is extremely limited, the fourth- and fifth-digit designations are crucial.
 
Shortening, or "truncating," your diagnosis codes means that you fail to code your claims to the highest degree of specificity, which may cause immediate denials.
 
The opposite of this rule is true, too: You should never turn a three- or four-digit ICD-9 code into a longer code by adding zeroes. Note, for example, that the subarachnoid hemorrhage (430) and intracerebral hemorrhage (431) codes contain only three digits. If you report 430.00, your carrier may not be able to read the diagnosis and will therefore deny your claim.