Radiology Coding Alert

Of all the currents that muddy up ICD-9 coding , nothing stirs the radiology coding waters like medical necessity. But if radiology coders focus on what supports medical necessity  correct use of final diagnoses and signs and symptoms  they can take a big step toward ensuring that their practices are getting every penny of the reimbursement they deserve.

Coding consultants estimate that about 40-50 percent of all claims submissions result in denials unless the practice uses targeted proactive processes to prevent such denials. Half of those denied claims are medical-necessity denials, says Joe Lineberry, CPC, vice president of compliance for radiology services at Per-Se Technologies in Atlanta. The sheer volume should focus your attention, he says.

Radiology Coders frequently get stumped when it comes to telling the differences among a final diagnosis, incidental findings, and the signs and symptoms that prompted the service, says Donna Gullikson, CPC, IR-certified, the coding and collections division director for MCBS, a billing company in Augusta, Ga.

Coding guidelines in the Medicare Carriers Manual (MCM) specifically state that the radiologist's or physician's relevant final diagnosis (or diagnoses) must be reported unless the examination is normal  in which case the presenting signs and symptoms should be reported. In fact, section B3 4010 of the MCM contains a specific example of coding an x-ray study's relevant positive results, not the signs and/or symptoms.

Other payers, however, may have different requirements, and coders must communicate with representatives to determine which apply. In all cases, payers allow reporting the presenting signs and symptoms and even significant incidental findings in addition to, but not instead of, the final diagnoses.

According to Lineberry, coders get confused about how to identify the highest degree of certainty, which refers to the most clinically significant condition the patient exhibited during the visit or that was noted during the interpretation of the imaging examination.

For example, Lineberry says, if a radiologist performs a chest x-ray for cough (786.2) and fever (780.6) as ordering diagnoses, and the finding is pneumonia, then you should report pneumonia (486) as the primary diagnosis. This coding is in line with Medicare's instruction to code to the highest degree of certainty  pneumonia is a certain diagnosis. If the chest radiograph were normal in the above scenario instead of demonstrating pneumonia, you would report the cough and fever as the most specific diagnostic codes.

An incidental finding would cover a condition like cardiomegaly (429.3) or history of myocardial infarction (MI) (414.8), Lineberry says. Although it may be a legitimate finding, "that's probably not causing cough and fever." Note that you can code the presenting signs and symptoms, as well as the incidental findings, in addition to the certain diagnosis.

Cardiomegaly is a great example of an ambiguous incidental finding, Gullikson says. Without physician assistance, coders cannot determine whether cardiomegaly "can be used as a final diagnosis or whether it is a contributing factor to the patient's signs and symptoms," she says.

Lineberry reminds readers that a large percentage of examinations are negative, which means the coder and radiologist are both dependent on ordering signs and symptoms. No matter how frustrated you are, he says, "do not code incidental findings as primary diagnoses to get paid."

To meet medical necessity, coders must be very precise when they report diagnosis codes. Even when some medical terms appear to be the same, payers will accept one but not the other.

Sometimes, experts say, doctors don't know specifically which diagnoses establish medical necessity for a particular service and which ones don't. For example, some radiologists use edema (782.3) and swelling of limb (729.81) interchangeably. However, an insurer may allow "swelling of limb" to support an abdomen CT but will reject "edema." Physicians need to be aware that if they write "edema" on the report, that claim will likely be denied. Because payers' claims-processing systems can handle multiple diagnoses, you should report both ICD-9 codes if both edema and swelling of a limb are present.

Lineberry acknowledges that unclear documentation often clouds the crystal ball of specific diagnoses because ordering physicians don't document with a view toward specifying the existing codes. For example, he says, coders may have a tough time choosing between 518.3 (Pulmonary eosinophilia) and 793.1 (Coin lesion) if the ordering diagnosis is vague.

When issues like these arise, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., an Atlanta-based firm, talk with physicians. "If we can let them know about specific language that may cause a denial, they can be more precise in the future."

In nearly all scenarios when a diagnosis code is in question, more information virtually always helps coders and may result in payment instead of denial.

The highest ethical reimbursement often goes to those who work together. When radiologists, ordering physicians and staff collaborate closely, they get better patient histories. And patient history can be used in assigning a diagnosis code in the absence of a more specific related finding, Lineberry says. You can also go to the patient history "if the clinical indications that were provided by the ordering physician just weren't complete enough to identify a medically necessary diagnosis."

Gullikson also advises speaking with the referring physician, if necessary. The primary-care physician may not realize that the radiologist may not get paid if complete diagnosis information is not included with the orders. Any information collected from a send-back must also be documented in the patient medical record, she notes.

All these tools can contribute to a higher percentage of initial claims being paid, Lineberry says. "Driving up the percentage of initial first-time claim submissions that result in payment is the end goal. It's better for the radiologist, it's better for the coder or billing entity. It minimizes cost and maximizes the revenue appropriately and does it in a timely manner."

Besides these practice tools, Lineberry says, the best way to get your radiology service claims paid the first time is to become knowledgeable about national Medicare policy, as well as local carrier and third-party payer guidelines. When coders are aware of local and national diagnosis coding policies, he says, making that vital decision about which code(s) to use when several are available from the history and/or diagnoses is much less difficult.

Ultimately, coders should keep in mind that any diagnosis codes reported with radiology services must support medical necessity at the time the services were ordered. "There have to be valid symptoms to justify the exams," Parman reminds readers.