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 [...]