Radiology Coding Alert

Question: Is it necessary when a radiologist reports on an abdominal and pelvic ultrasound study to combine both body areas into one report, or should the radiologist document two separate reports, one for the abdomen and one for the pelvis?

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Answer: To support coding both services, the general view is that documentation needs to be complete enough that you can identify each distinct service. In other words, you want to be able to pinpoint orders, medical necessity, performance, and findings of each separately coded service. This goal is easier to achieve with separate reports or separate sections in the same report.

For instance: Suppose you’re coding for a female patient, and you need to determine whether documentation supports complete abdominal ultrasound code 76700 (Ultrasound, abdominal, real time with image documentation; complete) and complete pelvis ultrasound code 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete). For the abdomen code, you have to see evaluation of the liver, gall bladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava with information on any visible abnormalities. For a complete female pelvic study, documentation must show description and measurements related to the uterus and adnexal structures, endometrium, the bladder (if applicable), and any pelvic pathology.

Checking off the long list of requirements is much simpler — for coders and auditors — if each code is supported by distinct documentation.

Medicare: Some consultants point to Medicare Claims Processing Manual, Chapter 12, Section 20.1, to support the importance of separating the reports: “For services furnished to hospital patients, carriers pay only if the services meet the conditions for fee schedule payment and are identifiable, direct, and discrete diagnostic or therapeutic services to an individual patient, such as an interpretation of diagnostic procedures and the PC of therapeutic procedures. The interpretation of a diagnostic procedure includes a written report” (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf).

ACR: The American College of Radiology (ACR) also suggests dividing the documentation for easy identification. A 2009 Coding Source Q&A regarding abdominal and pelvic CT states, “It is not required that a radiologist dictate separate reports when abdominal and pelvic computed tomography scans are performed at the same setting. However, separate paragraphs or sections are strongly encouraged to facilitate coders doing their jobs and to help ensure that practices are not disadvantaged during audits, etc.” The article adds, “The ACR and American Medical Association published in Clinical Examples in Radiology (Fall 2006) the need to properly identify separate procedures in a report. The example given is ‘If separate, distinct, and complete studies of the knees, hips, and ankles are performed, then each study should be dictated in separate reports or under separate headings within one report.’”

The Q&A is online at http://gm.acr.org/Hidden/Economics/FeaturedCategories/Pubs/coding_source/archives/JanFeb09/QA.asp. Note that it was published before the creation of the combined abdominal/pelvic CT codes (74176-74178).