Radiology Coding Alert

This expert strategy gets you in the money and out of the auditor's aim

If you're coding based on the referring physician's orders rather than on what the radiologist interpreted for x-rays, you could be providing incorrect information to your insurer and risking hefty fines. Use these two steps to be sure you're submitting compliant claims when you code for radiology studies.

Step 1: Verify the Number of X-Ray Views

Example: Your group uses the internal code "Left wrist routine three views" to order a three-view wrist x-ray. You get a report with this name, but the body only indicates the findings, not how many views were taken.

Snag: Trusting the name to be accurate could get you in trouble. If the physician doesn't dictate the name of the study, it may not reflect what he actually did, says Blake A. Johnson, MD, director of CNS imaging at the Center for Diagnostic Imaging in Minnesota. Johnson suggests checking with the doctor or the technician to confirm how many views were done.

Many reports come in with headers that only show what was ordered, says Donna Gullikson, CPC, RCC, CIC, division director and coding supervisor for MCBS, a healthcare provider management company in Augusta, Ga. Because of this, Gullikson recommends coding directly from the radiologist's dictated report. Basing your decision on the report is especially important for Radiology Coder , thanks to the Additional Diagnostic Test Exception in section 15021 of the Medicare Carriers Manual (see www.cms.hhs.gov/manuals/pm_trans/r1787b3.pdf for more information). This exception allows radiologists to perform tests that were not ordered, but only under very specific conditions.

Hidden trap: You need to "find out where your radiologist's dictation starts," Gullikson says. If the physician dictates the header, make sure you know if he's stating the order or what he actually did. Radiologists, technologists, transcriptionists, and the billing staff all need to have a common understanding of the office routine and stick to it.

Lesson: Don't make assumptions about how many views were taken or what test was performed. Check before you code. But many payers follow the old adage that "if it wasn't ordered, it wasn't done," experts say. By coding for something that is done because of standing orders or protocol, without true orders proving its medical necessity, you risk denial and severe audit consequences. Frankly, a patient won't want to pay you for something not medically necessary, either.

Avert disaster: Help prevent these problems by establishing a routine. The radiologist should always dictate the formal name of the study being interpreted, including the number of views. You may also want the policy to require the radiologist to confirm that the header is either correct or incorrect based on the study, and if it is incorrect, have him dictate the correction. Even if your practice uses a Radiology Information System (RIS), this method allows for improved exam information.

Step 2: Demonstrate the Benefits of Adequate Reports to Your Doctor

If you can show the radiologist the difference between full reimbursement and the amount he'll get for inadequate documentation, chances are he'll start to report his services properly.

For example, he performs a neck CTA (70498, Computed tomographic angiography, neck, without contrast material[s], followed by contrast material[s] and further sections, including image post-processing), but all that's documented is a neck CT, with and without contrast (70492, Computed tomography, soft tissue neck; without contrast material followed by contrast material[s] and further sections). Tell the radiologist that you code what he documents, so he just lost himself about $150.

Tip: Johnson recommends stressing to the doctor the pain of an audit and the large sums he'll potentially lose if insurers sue him for fraudulent claims.

If that doesn't work, the ACR has Standards for Communication, and you should remind your physicians of these standards annually, Gullikson says. If there's a particular radiologist who is not abiding by the guidelines, prove to him "how many you had to down-code within a given timeframe," Gullikson says. Concrete proof of how much money a doctor is losing may be just what he needs to learn responsible documentation. You can access these standards for diagnostic radiology at www.acr.org/s_acr/bin.asp?DID=541&DID=12196&DOC=FILE.PDF.

Fallback position: If the radiologist later tells you that he meant to dictate a certain test instead of what he actually did, he needs to dictate an amended report detailing the true procedure he performed. But remember that while addenda dictated to provide complete patient care information are acceptable, auditors may be suspicious that the physician added documentation just to increase reimbursement.