Radiology Coding Alert

The broad clinical utility of CTs has resulted in a gap between physician usage and strict coding definitions. When the ordering diagnoses cause consternation, you can employ several different methods to manage physician awareness and perform the appropriate exam.

Mark McElroy, CPC, a Radiology technician at University Health Services in Augusta, Ga., offers these tips:

1. Make sure the referring physician's indications (diagnoses, signs and symptoms) for the CT match the CT ordered. McElroy says the old saw about "atrocious" physician handwriting can come to life when abbreviations like "hd" (for head) and "abd" ( for abdomen) are scrawled on orders.

2. If the radiologist has any questions about initial indications or exams ordered, the referring physician should be contacted and the order should be properly revised for the record prior to performing the CT to allow correct coding of both indications and CT exams of the abdomen and pelvis. This is the ideal method. McElroy says: "That way you can determine whether the error lies in the diagnosis or the exam ordered."

3. As a supplementary option, you can interview and interact with the patient to find out what the problem is.

4. Remember to look for additional indications reported by the radiologist upon completion of the CT.

When confronted by vague directions from an ordering physician, the bottom line is that if it's something that's going to provide suboptimal care, then the radiologist has the latitude to change the order, says Cheryl Schad, CPC, CPCM, owner of Schad Medical Management in Mullica Hill, N.J. For example, under Medicare rules, if a physician has ordered a contrast study and the radiologist feels that a contrast study is redundant to fulfilling the requesting physician's need, the radiologist can make that determination to downcode the ordered service without contacting the requesting physician.

With the exception of diagnostic and screening mammography, in a private office or an IDTF (independent diagnostic testing facility) any adjustment that will add to the RVUs must take the form of written documentation between the radiologist and the requesting physician, Schad says. Radiologists treating hospital inpatients, ER patients, or outpatients in the hospital or facility setting are exempt from this documentation requirement.