Radiology Coding Alert

Of all the currents that muddy up ICD-9 coding , nothing stirs the radiology coding waters like medical necessity. But if radiology coders focus on what supports medical necessity  correct use of final diagnoses and signs and symptoms  they can take a big step toward ensuring that their practices are getting every penny of the reimbursement they deserve. Coding consultants estimate that about 40-50 percent of all claims submissions result in denials unless the practice uses targeted proactive processes to prevent such denials. Half of those denied claims are medical-necessity denials, says Joe Lineberry, CPC, vice president of compliance for radiology services at Per-Se Technologies in Atlanta. The sheer volume should focus your attention, he says. Coding Final Diagnosis Versus Symptoms Radiology Coders frequently get stumped when it comes to telling the differences among a final diagnosis, incidental findings, and the signs and symptoms that prompted the service, says Donna Gullikson, CPC, IR-certified, the coding and collections division director for MCBS, a billing company in Augusta, Ga.

Coding guidelines in the Medicare Carriers Manual (MCM) specifically state that the radiologist's or physician's relevant final diagnosis (or diagnoses) must be reported unless the examination is normal  in which case the presenting signs and symptoms should be reported. In fact, section B3 4010 of the MCM contains a specific example of coding an x-ray study's relevant positive results, not the signs and/or symptoms. Other payers, however, may have different requirements, and coders must communicate with representatives to determine which apply. In all cases, payers allow reporting the presenting signs and symptoms and even significant incidental findings in addition to, but not instead of, the final diagnoses. According to Lineberry, coders get confused about how to identify the highest degree of certainty, which refers to the most clinically significant condition the patient exhibited during the visit or that was noted during the interpretation of the imaging examination. For example, Lineberry says, if a radiologist performs a chest x-ray for cough (786.2) and fever (780.6) as ordering diagnoses, and the finding is pneumonia, then you should report pneumonia (486) as the primary diagnosis. This coding is in line with Medicare's instruction to code to the highest degree of certainty  pneumonia is a certain diagnosis. If the chest radiograph were normal in the above scenario instead of demonstrating pneumonia, you would report the cough and fever as the most specific diagnostic codes. An incidental finding would cover a condition like cardiomegaly (429.3) or history of myocardial infarction (MI) (414.8), Lineberry says. Although it may be a legitimate finding, "that's probably not causing cough and fever." Note that you can code the presenting signs and symptoms, as [...]