Radiology Coding Alert

Date, procedure details, impressions, and physician signature are key.

Radiology claims are challenging due to specific documentation requirements for procedures performed. “To put it in simple terms, if documentation does not support the procedures or diagnosis, you do not get payment,” says Dianne Nakvosas, ACS-RAD, Compubill, Inc., IL.

Complete documentation is a requisite for clean claims. You should retain the actual radiology images, written reports with details of medical necessity for the radiological assessment and the final impressions of the procedure performed. In addition, you should also maintain the order or request for the radiological procedure.

Here is a concise checklist for complete documentation:

1. Name of patient and referring physician and relevant history of the patient
2. Indication or reason for the radiological examination
3. Date, time, and procedure statement of study performed
4. Extent of radiological assessment (limited, complete), if applicable
5. Number and type of views taken (bilateral, left, right) and comparison of the views or comparisons with studies conducted earlier
6. Contrast material, if any was used. Mention details of contrast, and the amount and method of administration
7. Recommendations for follow-up examination, repeat examinations, and any additional assessments
8. Any study limitations, for example: poor image quality
9. Results, impressions, and final conclusions
10. Signature of radiologist.

Tip: Reach out to the provider for any insufficiency in documentation.