who is responsible-radiology orders


Local Chapter Officer
Best answers
I work for a small local hospital and I have come across a situation to where I would like my fellow coders ideas and info. One of my job duties is to code diagnostic radiology reports. When I come across a report, and the radiologist does not find anything, I use the diagnosis off of the order. However sometimes I come across orders that do not have a diagnosis that supports the imaging done or it state to "rule out" or "vs.". For example, Headache R51 for a foot x-ray. So what I do is contact the patient access person who registered the patient and scanned in the order. I ask them to contact the physician office to get a new order with a dx that would support the imaging done. Once a new order is scanned in I code it.

Now my new Manager and Higher Up, say that the coders need to contact the physician office for new orders. My question is, shouldn't the inconsistency of the diagnosis and the imaging being done (and the "rule out" and "vs.") have been caught by by patient access person who is registering and scanning order? Should it have been caught by the radiology tech before performing the imaging? Should I not query for a new order and use the diagnosis that is already there (headache R51)? I don't see how it can go through the system then I am the one who notices it.

Some examples that I have come across

Order for Screening Mammogram and diagnosis of Z01.419 (encounter for gynecological examination)
Order for ultrasound on bladder and diagnosis of Z00.129 (encounter for well child examination without abnormal findings)
I also get order saying to "rule out" or "vs." two different diagnosis.

Any input would be greatly appreciated.
A couple thoughts come to mind that might help:

First of all, I recommend against getting a 'new order'. Medicare does not accept retroactive orders and it could be a compliance issue if you're coding off of orders dated after the test was done or asking providers to go back and add information to the medical record after the fact (refer to this publication on Medicare signature requirements https://www.cms.gov/Outreach-and-Ed...gnature_Requirements_Fact_Sheet_ICN905364.pdf).

Now if your orders have missing or incorrect information, it is acceptable to contact the ordering provider to get the correct information either in writing, or by phone or email, and your facility should keep a record of those communications. Here's a good document that outlines this - in particular, see section B: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/ab01144.pdf.

Lastly, as for who should be responsible for getting what information - that is really a management decision that your organization needs to make to determine after considering the best use of resources. It does make sense to me that errors and problems with order would be caught up front rather than downstream in coding after the services have already been completed, but without knowing what your facility's systems or staffing abilities are it's hard to provide input on this. I worked in a small facility where we had software in place that allowed the registrars to validate the diagnosis and procedure ahead of time. This worked well because if there was a medical necessity issue or problem with the order, it could be identified and corrected, or ABNs could be obtained before the procedure was done to prevent denials or loss of revenue. I'd suggest you try to make the case to your managers that a change in process would be a practice improvement, but be prepared for some push-back. The problem of coding and billing having to deal with errors that occurred some upstream in the process has been an issue everywhere I've worked - it's somewhat a fact of life in this business and isn't likely to go away any time soon.
Welcome to the world of coding. I've been in the coding arena over 30 years and it hasn't changed one bit.