Radiology Coding Alert

Plus, make sure dictation report structure meets ACR standards.

If you feel occasionally overwhelmed by the plethora of guidelines to keep track of within the radiology specialty, you’re not alone. Between the National Correct Coding Initiative (NCCI, or CCI) Policy Manual, CPT^® and ICD-10-CM manuals, and handful of other authoritative sources, it’s your job to keep track of each respective set of guidelines.

However, there’s one fundamental set of guidelines that often goes overlooked within the radiology specialty — the American College of Radiology (ACR) Practice Parameters and Technical Standards. “The ACR Practice Parameters and Technical Standards provide a comprehensive set of rules for coders, radiology technicians, and physicians to abide by,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “These parameters are outlined by modality (radiography, computed tomography [CT], etc.) and organ or body system,” Rosenberg explains.

Remain confident and compliant by addressing a few of the most important ACR Practice Parameters surrounding general radiography and diagnostic imaging.

Know What Qualifies as Medical Necessity

Beginning in the Practice Parameter for General Radiography section, you’ll want to have a look at these instructions to make sure that medical necessity is met on the imaging order form:

• “The written or electronic request for general radiography should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation.”

The ACR further elaborates on what specific criteria the provider needs to document in order for a written or electronic request to qualify as medically necessary. Specifically, the ACR lists the following criteria that needs to be included on the order to satisfy medical necessity:

• “Signs and symptoms and/or;
• Relevant history (including known diagnoses).”

Along with these criteria, the ACR states that “additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination.” The ACR does not further elaborate on what constitutes a “provisional” diagnosis, but referring providers should be cautious not to include any non-definitive diagnostic terms (probable, suspected, etc.) unless there are signs and symptoms included in the order as well.

Examine Full Spectrum of Dictation Report

Next, have a look at a few guidelines that you should keep an eye out for within the dictation report itself. In the Practice Parameter for Communication of Diagnostic Imaging Findings, the ACR lays out some rules that physicians must adhere to in the process of dictating their imaging reports. Have a look at the following two guidelines that coders need to be acutely aware of:

• “The report should address or answer any specific clinical questions. If there are factors that prevent answering the clinical question, this should be stated explicitly.”
• “Unless the report is brief each report should contain an ‘impression’ or ‘conclusion.’”

With parameters such as these, coders are the last line of defense before a claim gets submitted based on a dictation report that’s not up to code. While a radiology coder may traditionally be on the look out for errors in the exam header, technique, body, and impression, having a look for certain contextual mistakes or omissions is important as well. With respect to the first parameter, this means that the radiologist should always clearly explain why a clinical indicator is unidentifiable. For instance, if motion artifact on an MRI prevents the provider from conclusively identifying a suspected condition, it needs to be clearly stated in the impression. On the other hand, if dense breast tissue restricts visibility on a mammogram, this too should be properly documented in the impression of the report.

The second parameter, while seemingly insignificant on the surface, is important to always consider when evaluating dictation reports of various modalities. Most coders will attest that, every now and then, a dictation report comes along that is clearly missing one or more key features. “Usually, I’ll come across reports missing either the technique or specific wording integral to the procedure performed,” says Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “If you find that a portion or the entirety of the impression is missing, you should consider the report incomplete and send it back for an addendum,” Della Vella advises.

Check for Pertinent Dictation Report Criteria

Finally, on the subject of dictation reports, you should be conditioned to perform a criterion check on each report before beginning to analyze the report’s contents. The ACR labels each structural component of the dictation report that coders should identify before making any coding considerations:

• “The facility or location where the study was performed;
• “Name of patient and another identifier;
• “Name(s) of ordering physician(s) or other health care provider(s). If the patient is self-referred (a patient who seeks medical care without referral from a physician/health care provider), that should be stated;
• “Name or type of examination;
• “Date of the examination;
• “Time of the examination, if relevant (eg, for patients who are likely to have more than one of a given examination per day).”

Additionally, the ACR “encourages” the inclusion of the following items:

• “Date of dictation;
• “Date and time of transcription;
• “Patient’s date of birth or age;
• “Patient’s gender.”

These are only a few of the practice parameters that you should be considering when coding diagnostic radiology reports. For the complete list, visit https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards.