Diagnostic Radiology Coding – Tips to Ensure Clean Claims

Diagnostic Radiology Coding – Tips to Ensure Clean Claims Medical coding for the radiology specialty is constantly changing. The article provides certain tips for medical coders to ensure submission of error-free claims.

With regular updates and changes in codes, radiology medical coding poses unique challenges for medical coders. Diagnostic Radiology includes all the subspecialties in the area

of

imaging:

X-ray

(including

fluoroscopy),

Ultrasound

(including

non-invasive

vascular), Computed Tomography (CT) (including CT angiography), Magnetic Resonance (MR) (including MR angiography), and Nuclear Medicine.

Most imaging tests (except for self-referred screening mammograms) start with an order from a referring physician. While documenting imaging services, it is critical for radiology coders to stay abreast of the current diagnostic radiology coding rules.

Tips Medical Coders Can Consider  Consider the minimum requirements - Medical coders must make sure that the reports meet minimum requirements recommended by the American College of Radiology (ACR). All dictated radiology reports must contain details including Heading (study name), Number of views or sequences (name of views – what was done), Clinical indication (reason for exam), Body of report (findings), Impression or conclusion (synopsis of findings), Physician signature, and Diagnostic studies (plain films).  Get familiar with the radiology components – Radiology procedures include technical component, professional component and global service. While technical component is the use of equipment and supplies and the employment of radiologic technologists to perform diagnostic imaging tests and administer radiology therapy treatments, professional component is the services provided by the physician, which include supervising the performance of a diagnostic imaging procedure, interpreting imaging films and documenting the imaging report. Both the components are combined in the global service and are documented with a CPT radiology code. The coder must know whether to report a technical, professional, or “global” service.

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To report only the technical portion of a service, add modifier TC Technical component.

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To report only the physician work portion of a service, use modifier 26 Professional component.

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When reporting global services, modifiers TC and 26 are not required.

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 Report the documented number of views - The number of views stated in the medical report must meet the basic requirements of the CPT® code reported. Let us consider a code – 

73564 Radiologic examination, knee; 4 or more views

In this case, even if the physician states “AP, lateral, and both obliques,” instead of “four views,” it is acceptable. Also make sure that the number of views must be listed in the physician order. If the number of views is not given in the order, it is recommended that the radiology department or office contact the referring physician and ask for a new order indicating the views he would like performed.  Documentation must be complete with image documentation - Permanent image documentation is critical. To code for a complete exam, abdomen and retroperitoneal studies have strict documentation requirements such as –

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A complete abdomen study requires documentation of the liver, gall bladder, common bile ducts, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava.

76700 Ultrasound, abdominal, real time with image documentation; complete



If any one of the required anatomy is not documented, the study must be down-coded to a limited exam.

76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ,



quadrant, follow-up)

A complete retroperitoneum study consists of documentation of the kidneys, abdominal aorta, and common iliac artery origins.

76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete

By submitting clean claims, radiologists can receive timely reimbursement. HIPAA-compliant medical coding companies ensure easy submission and retrieval of documents without any security breach.

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