Radiology Coding Alert

Experts have several tricks up their sleeves for educating ordering physicians about coding with medical necessity in mind.

One powerful physician education tool is to analyze percentages of denials by modality. Ask your practice which procedure codes result in the highest relative frequency of denials, says Joe Lineberry, CPC, vice president of compliance for radiology services at Per-Se Technologies in Atlanta. Also ask what your most common diagnosis is for those denied services. Then, based on this analysis, create an order form that the radiologist or coder can provide to ordering physicians to help them document medical necessity completely. Remember its not the dreaded coding "cookbook" if you stick to documented medical necessity.

For example, in Florida, Lineberry says, a brain MRI for headache (ICD-9 784.0 ) is not a payable diagnosis. "If you do the MRI for a headache and find a tumor, I would certainly code the tumor as the primary diagnosis," he says "Unfortunately, if you have only headache on the ordering diagnosis and the MRI is negative, you would have to fall back on ordering diagnosis and you wouldnt get paid."

You can sometimes sidestep this problem if you provide more specific codes that describe in more detail the varieties of headache that might have engendered the study, such as cluster headaches (346.2x, Variants of migraine) or other visual anomalies (368.8, Other specified visual disturbances).

To elicit more specific diagnosis codes from physicians, Lineberry suggests that practices create a form that includes the top-10 payable diagnosis codes for a brain MRI. However, he cautions, dont stop there or you may have a serious compliance risk on your hands. Because you dont want to lead the physician, you should also create a column that includes the top-10 nonpayable diagnosis codes. At the very least, coding consultants agree, you should include a blank for "other" and instructions to specify the exact "other" diagnosis not listed on the form.

If you include both payable and nonpayable diagnoses on the form, it can function as an educational tool, Lineberry says. The physician will know that shes sending a patient to a radiologist for a nonpayable, nonmedically necessary diagnosis. At that point, if the patient is still present, the ordering physician may take the opportunity to ask additional questions such as, Have you had visual disturbances with your headache? If the patient says "yes," now you have a legitimately payable diagnosis. Similar further detailed clinical information can and should be obtained by the radiology office during patient intake.