Radiology Coding Alert

It's your practice's job to recommend an appropriate fee

If you perform a procedure for which CPT Codes doesn't include a code, chances are your only option is to report an unlisted-procedure code, submit a written report to the carrier, and hope for the best. To ensure that your payer properly rewards your unlisted-service claims, our experts offer three tips. Step 1: Describe the Procedure in Plain English When you report an unlisted-procedure code (for example, CPT 76499, Unlisted diagnostic radiographic procedure), you should submit a full operative report to describe the procedure or service - but when it comes to fair reimbursement, the operative notes alone won't be enough. You should include a separate report that explains in simple, straightforward language exactly what the radiologist performed.

"There's no 'standard' fee for an unlisted-procedure code," says Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno. "Insurers consider claims on a case-by-case basis and determine payment based on the documentation you provide. Unfortunately, claims reviewers, especially at lower levels, do not have a uniformly high level of medical knowledge, and physicians don't always dictate the most accessible notes." Submit Great Documentation, Collect Great Pay The radiology coder should act as an intermediary between the radiologist and the claims reviewer, providing a description of the procedure in layman's terms.

"If the person making the payment decision can't understand what the physician did, there's not much chance that the reimbursement you receive will properly reflect the effort involved," says Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Brick, N.J. Be careful to avoid or explain medical jargon and difficult terminology. And, if appropriate, you may include diagrams or photographs to better help the insurer understand the procedure.

For example, CPT Include no specific code to describe an x-ray of the entire leg using a single film, so you should report 76499 for this service. To describe the procedure, you should use the radiologist's notes as a guide, stressing the main points of the procedure and why it was necessary.

A sample narrative might read, "The orthopedic surgeon ordered a complete leg x-ray on the same film to detect possible bone abnormalities. We performed a full-leg x-ray in both the standing and supine positions."

"A little extra effort to write a clear description of the procedure can go a long way toward improving your reimbursement," Cobuzzi says. Step 2: Compare the Procedure You Performed to a Procedure [...]