Radiology Coding Alert

Radiology coders nationwide are reporting a wide range of problems with the denial of payment for preoperative chest x-rays (71010, single view or 71020, two views). This is mostly due to unacceptable diagnosis coding (ICD-9-CM Codes ) to justify the medical necessity of the examination. Unchecked rises in denials for pre-op chest films can cause heavy demands for follow-up, recoding, rebilling, higher write-offs, and significant risk exposure for coding noncompliance. Practices may be underestimating the significance of hidden losses from these denials.

To maximize appropriate payment for preoperative chest x-rays, develop a coding strategy based on answers to the following four questions:

1. How Big is the Problem of Denials for your Practice?

The challenge of payer denials for routine preoperative chest x-rays can be described with a common scenario familiar to many radiology coders: Surgeons refer just about every patient for a chest x-ray prior to surgery, taking for granted that it is a routine standard of care. Thus, the order for the pre-op chest x-ray often fails to include sufficient information for the radiology practice to establish the appropriate reason for the examination.

Faced with a large number of chest x-rays to code (all after the fact), the radiology coder may have a tendency to simply select a default ICD-9 Code , such as V72.81 (preoperative cardiovascular examination) or the safer default code V72.82 (preoperative respiratory examination). The claims are submitted to payers, and any problems are left to be dealt with as denials occur on a case-by-case basis.

Sometimes use of a default V code works and the claim gets paid. For example, in some states (such as Tennessee and Georgia), the local Medicare carrier was denying claims using V codes, but now instructs coders simply to use one of the default V codes V72.81 to V72.83, assuming the surgeons medical record for the patient has the necessary indications to justify preoperative chest films. However, this practice of using default V codes produces a pattern that payers may interpret as indiscriminate use of preoperative chest x-ray, which could lead to payment denials as well as a higher risk of a coding audit. For example, Jane Smith, practice manager, and members of the staff at Gainesville Radiology in Georgia, report that the same V codes that get payment from Medicare are regularly denied when a pre-op chest x-ray is submitted to Medicaid, Champus and some commercial payers.

Furthermore, Susan Callaway-Stradley, CPC, CCSP, an independent coding consultant in Augusta, GA, and the American Academy of Professional Coders 1998 Coder of the Year, says that even if such claims are paid, if the codes are not consistent with the medical record of the referring surgeon, an audit may find the radiology coding is not in compliance with applicable laws and regulations for correct coding. Thus, your practice could be fined and be required to repay the previous reimbursement you received for the claims.

2. Who is Denying Claims and Why?

Before investing time and resources to check any one payer, use this simple procedure to find out the size and sources of the denial problem for your practice related to pre-op chest x-ray codes. Run a report from your billing system listing and counting claims for chest x-rays (71010 or 71020) that have been denied. Sort the claims by payer and ICD-9 Codes .

Note: If your billing system will not produce a report of denials for a particular CPT Codes with sort options for payer and diagnosis code (ICD-9), this is a valuable item to discuss with your information system vendor.

Next check to see which payers account for significant numbers of denials. Dividing the number of pre-op chest x-ray denials by the total number of chest x-rays for a given period provides a measure of that payers rate of denials. For example, if a radiologist performs 1,200 chest x-rays over six months (200/month) and Medicaid denials for the same period amounts to 60 (10/month), then the denial rate is 60/1,200 or 5 percent. Use this measure to rank all payers who deny payment and to look for trends over time. Chances are the payers who make the Top 10 List based on frequency of denials will account for the majority of them. Check these further to look for the ICD-9 codes that tend to be denied most often. With this information you can prioritize follow-up of denials focusing first on payers causing the biggest losses and ICD-9 codes most often denied. This will help produce the biggest bang for your resource bucks invested in coding follow-up.

3. What are Coding Standards for Pre-op
Chest X-rays?

With a handle on the size and sources of the denials of pre-op chest x-rays for your practice, next make sure you know the standards that are the basis for correct coding. The American College of Radiology (ACR) standard states, Preoperative radiographic evaluation is indicated if cardiac or respiratory symptoms are present or if there is a significant potential for thoracic pathology that may compromise the surgical result or lead to increased perioperative morbidity or mortality (source: ACR Standard for the Performance of Pediatric and Adult Chest Radiography, effective 1/1/98).

State Medicare carriers have a similar standard based on national guidance that uses language, such as preoperative chest x-rays are covered if the patient is scheduled for major surgery and has risk factors which make the x-rays necessary. The risk factors must be clearly stated in the patients medical record.

Now the problems with the typical coding scenario described above should be coming into focus. Surgeons who continue to order pre-op chest x-rays without providing proper indications need to know that this practice does not meet accepted professional and payer standards, causes unnecessary administrative costs and financial losses for the radiology practice, and places both the hospital and the physicians at risk for coding noncompliance.

Second, coders should be aware that the use of V codes, such as V72.82 (preoperative respiratory examination), does not document any indication for a pre-op chest x-ray to meet standards. Some coders may feel that if the V code gets the claim paid why be concerned? As Callaway-Stradley observes, To meet the standards, the patient still must have an underlying medical condition which is an appropriate reason to have a pre-op chest x-ray. For example, an otherwise healthy middle-aged male who is a nonsmoker with no history of any cardiac problems has no indications which call for a pre-op chest film. However, a 75-year-old male smoker with a defined cardiac condition has the risk factors that probably require one.

Although V codes can get claims paid for some payers some of the time, Callaway-Stradley contends that reliance on V coding leaves the radiology practice at the mercy of the payer with no indications to support the claim should it be denied.

4. What Strategies Work to Reduce Denials?

Most radiology practices and their coders use a back-end strategy. This means that action is taken only after a payer denial. Individual denials are checked for correction of coding or additional coding, and either recoded and refiled (if follow-up results in an appropriate ICD-9 code) or written off. The advantages of this coding strategy are that it does not require surgeons to change their habit of ordering routine pre-op chest films, and it does not require review of ICD-9 coding for the first claim submittal. So initial claims submittals are not delayed. The disadvantages of a back-end strategy are: follow-up of denials produces significantly less revenue per claim than initial clean claims; follow-up is labor intensive and may even consume more practice resources than the revenue salvaged; and, if the coder is unable to support a proper ICD-9 code, the result may still be a write-off with more wasted resources.

Even with its disadvantages, a back-end coding strategy may be all that is possible. However, some practices are trying to develop a front-end coding strategy. This means surgeons are required to provide appropriate indications with all orders for preoperative chest x-rays. Instead of using default V codes, coders are then required to code specific indications that meet the standards supporting medical necessity for a pre-op chest film. A list of accepted diagnosis codes for the disease process being evaluated can be obtained from your carrier. The exact order listed on the claim form needs to be verified with your carrier prior to submission.

Callaway-Stradley suggests that the best way to implement this front-end strategy is to create a form (using the payer-approved diagnosis list) for the surgeon to order the examination, which specifically requires appropriate indications with the order. The advantages of this strategy are that it provides the coder with the appropriate indications to code correctly with the first claim and thereby reduce denials; it increases clean, first claims; it reduces risks of coding noncompliance; and it should result in increased payments.

The disadvantages are that it requires a change in ordering procedures and forms, it requires coders to check specific codes with the first claim, and it means a change in the ordering habits of the surgeons. All considered, radiology practices are well advised to utilize a front-end coding strategy.