Radiology Coding Alert

When doctors jumble exam reports, auditors may target your claim

You know your physician's documentation isn't always perfect, and we've got a real-life example right here. Read through the report and determine how you would code. Then turn to page 14 to see what our radiology coding expert has to say.

CLINICAL HISTORY: Follow-up sigmoid colon cancer with pulmonary metastasis.

CT SCAN OF THE CHEST, ABDOMEN, AND PELVIS WITH CONTRAST

TECHNIQUE: 5-mm sections through the chest, abdomen, and pelvis were obtained with 100 cc of Isovue 300 (non-ionic) contrast agent intravenously without incident, and oral contrast and images viewed in soft tissue, lung, and liver windows. Comparison is made with a previous examination performed on 06/02/06.

Indication for the use of non-ionic contrast: No specific indication given.

FINDINGS: Again, there are several pulmonary nodules bilaterally, consistent with metastases. The majority of the previously seen nodules have either decreased in size or resolved. There are new pulmonary nodules. The previously seen scattered ground glass opacities, most prominent at the left lung base, have resolved. The previously seen prominent subcarinal and left hilar lymph nodes have decreased in size as well. Subcarinal lymph node measures 7 mm x 19 mm on image #28. Previously, it measured 11 mm x 26 mm.

There is no bulky axillary, mediastinal or hilar lymphadenopathy. The heart is stable. Left subclavian Infuse-A-Port catheter has been placed in the interim.

Previously noted hypodensity within the dome of the liver is less conspicuous and actually appears to be volume averaging within the perihepatic fat. The hypodensity within the medial aspect of the left hepatic lobe is adjacent to the falciform ligament in a good place for fatty infiltration. Otherwise, the liver is normal. Gallbladder, spleen, pancreas, adrenal glands and kidneys are stable. A simple cyst is seen within the parapelvic region of the right kidney.

There is moderate symmetric concentric thickening involving the distal sigmoid colon which is less nodular when compared to previous examination. Again, there is mild increased attenuation of the perisigmoid and rectal fat, which may be related to radiation therapy changes. There is mild sigmoid and descending colon diverticulosis. Otherwise, the bowel is unremarkable. No bulky lymphadenopathy or ascites. Mildly prominent celiac axis lymph node is unchanged. Best seen on image #86, just posteromedial to the spleen, there is a 6- x 15-mm soft tissue density nodule along the posterior peritoneal surface that is nonspecific but unchanged from prior examination.

IMPRESSION:

1. Persistent but improved bilateral pulmonary metastases.

2. Mildly prominent subcarinal and left hilar lymph nodes have decreased in size. Mildly prominent celiac axis lymph node is stable.

3. Hepatic hypodensities likely represent a combination of volume averaging and focal fatty infiltration. There is no new hepatic lesion to suggest metastasis.

4. Persistent left nodular sigmoid colon wall thickening. Adjacent mesenteric and induration may be related to radiation therapy changes.

5. Stable small nodule along the left posterior peritoneal surface is stable.

QUIZ ANSWERS:

Did you come up with the same answer as our coding expert?

If you had perfect documentation, you would be able to report the following, says radiology coding consultant Cheryl Schad, BA Ed, CPC, ACS-RA, owner of Schad Medical Management based in Mullica Hill, NJ:

1. CT chest with IV contrast ...quot; 71260 (Computed tomography, thorax; with contrast material[s]) and 197.0 (Secondary malignant neoplasm of respiratory and digestive systems; lung)

2. CT abdomen with IV contrast ...quot; 74160 (Computed tomography, abdomen; with contrast material[s]) and 153.3 (Malignant neoplasm of colon; sigmoid colon)

3. CT pelvis with IV contrast ...quot; 72193 (Computed tomography, pelvis; with contrast material[s] ) and 153.3

4. 100 units of contrast ...quot; Q9949 (Low osmolar contrast material, 300-349 mg/ml iodine concentration, per ml).

Limit Code Choices Based on Documentation

Because you can only separately identify the CT chest in the physician's documentation, that's the only one you should code, Schad says. The CT chest is described in the first paragraph of "Findings," she says. But the next two paragraphs discuss elements of both the abdomen and pelvis. The two exams "must be separately discernable," Schad says.

Don't Overload Claim With Background Codes

Outpatient note: You don't need to include a code to indicate that the patient has been undergoing radiation therapy. Unlike hospital medical records abstraction, "with outpatient reimbursement coding, we must establish medical necessity, and once that has been established, there is no reason to add anything additional to give the insurance carrier an excuse to deny our claim for submitting ICD-9 codes that do not appear on their payable diagnosis list," Schad says.

You also don't need to change your coding just because this is a follow-up exam. "The findings confirm the reason for these studies," Schad says.

Count Up the Cost of Poor Documentation

"The very first problem with the documentation is the fact that there are three studies documented as one continuous report. This does not meet Medicare's (and many private insurance carriers') requirement for 'separate and distinct' documentation for each CPT code you are going to bill," Schad says.

If you report all three studies, an insurance auditor who reviews the report during a post-payment audit would likely only approve payment for the CT pelvis because it has the lowest RVUs of the three exams, Schad says. That means the payer would demand its money back for the chest and abdomen CTs.

Helpful: Let your physician know that documenting each exam as a complete and separate report will earn him roughly $960 for three exams instead of just $311 for the pelvis exam.

"At the very least, they should be dictated as though they were on separate reports," Schad says.