Radiology Coding

Radiology Coding

Keys for Successful Documentation, Compliance and

ReimbursementJuly 31, 2008

Denver, Colorado

Panelists• Martin Auster, MD, MBA, Johns Hopkins

University School of Medicine• Jeff Pilato, MHA, RTR, CPC-H, Health Record

Services• Beth Friedman, RHIT, Health Record Services

(presenting for Gerri Walk, RHIA, CCS-P)

The United Nations of Coding

Which hat do you wear?

Workshop Outline• Current state

– Common methods of coding– New models of coding

• Problems in radiology coding– Inadequate clinical documentation– Poor communication– Professional differences– Changing requirements

A Quick OverviewOP Radiology

• Goal is to provide clean claims• Small coding errors = big reimbursement problems• Biggest problems is coding accuracy• Six steps

1. Documentation2. Codes and charges3. Fee schedule4. Medical necessity5. CCI / OCE unbundling edits6. Modifiers and incorrect linkages

Current State

• Methods currently used for coding– Manual coding– Encoder coding– Computer-assisted coding– Combination / remote

• Who is coding?– Radiology department– Medical records department (HIM)– Combination / outsourced

Management ModelsModel Pros Cons What You

NeedHIM performs all coding

Already experienced general coders

No medical necessity training

Medicalnecessity workshop

Radiology Dept. performs all coding

Close to radiologists and techs

Minimal coding training

More coding training for Dx. Need qualified coders! RRS

Radiology Dept. codes / HIM oversees

Best of both Requires good relationship / division of duty

Strongleadership and communication

Outsource Experienced radiology coders. Steady flow (cash and coding)

Not physicallyclose to radiology

Liaison

Case Study• Large, academic medical center in Midwest• 800 – 1,200 studies per day• Problem

– Can’t find coders / space / salaries & benefits– Ramp up time for new hire

• Solution– Outsource physician component– Certified, U.S. coders– Saved space/improved quality/experienced team

Tips for Success

• Set expectations and needs upfront• Identify liaison on both sides• Review edit reports every day• Trend errors, partner to educate

How to Decide Which Model is Best for your Organization

• Criteria that can be used: – Size of the practice, volume of cases,

personnel, patient demographics, private practice vs. academic, hospital-based vs. imaging center

The Clinical Documentation Deficit

The Impact of Insufficient Documentation

• Lost revenue opportunities (under-coding)• Impact on quality scores and Healthgrades• Additional time spent by coders• Others

Impact on Revenue

• Documentation concerns– Lack of clarity

• Abdomen x-ray documented but lacking number of views

– Ill-defined separate/additional procedures• With or without duplex scan

– Single or multiple • NM cardiac blood pool studies

How to Improve Documentation

• Radiologist perspective (Dr. Auster)• Radiology administrator perspective (Jeff)• HIM and coder perspective (Beth)

Radiologist Perspective

• Examples of good and bad reporting – Show impact on reimbursement– Lump vs. split / bundle vs. package– Most don’t know

• Train young radiologists how to dictate• Use standard report templates

ARCH ARTERIOGRAM

ARCH ANGIO

IVC FILTER PLACEMENT

ILIACSTENT PLACEMENT

Standard Report Templates National Guidelines for Radiology Reports

American College of Radiology (ACR)General Information: Diagnosis

DocumentationProcedure Documentation

Identification of patient

Clinical hx, chronicconditions Signs, symptoms, reason for test If f/up test, f/up for what condition?

Name and type of exam

Referring physician Pertinent pos. and neg. findings

Limited, mult. areas, complete or whole body test

Date and time of procedure

Impression and/or DX. Number and type of views taken (unilateral, bilateral, right, left)

Comparative results (prior studies viewed for comparison)

Do not use rule out, suspected, probable and/or questionable statements

Type, amount and method of contrast media or radionuclide

General Information: Diagnosis Documentation

Procedure Documentation

Reason for test – sign or symptom

Single or multiple determination, qualitative or quantitative

Findings, results, impressions, conclusions

Number of sequences or slices

Limitations Poor film quality, patient body habitus, patient prep

Radiologist signature

Separate paragraphs with separate headings for mult. tests performed on one patient.Recommended f/up exam or diagnostic studies

Standard Report Templates National Guidelines for Radiology Reports

American College of Radiology (ACR)

Radiology Administrator Perspective

• Put process in place for reimbursement and documentation issues– Assign the right person as liaison– Track and trend errors, focus program– Report back to lead radiologist for peer-to-

peer education

Example Denial LogDate Procedure ProcCode Rejection Reason Action Result

1/6/2008 Post op cxr 71010 Medical Necessity edit Replaced V670.9 (post‐op CXR) with findings 5511.9 (effusion pleural NOS.)

Passed edit 2/14/08

3/10/2008 PET scan 78815 Medical Necessity edit Replaced 786.6 mass in chest with reason for test V10. 85 (personal history of Brain ca.

passed edit on 3/20/08

3/16/2008 Mammogram screening

77057 Medical Necessity edit Replaced V10.3 personal hx of breast ca with V76.12 mammo screening

passed edit on 3/20/08

4/12/2008 MRI of Brain 70544 Medical Necessity edit Codes correct according to report. Negative findings. Checked with ordering physician and 784.0 headache is correct diagnosis.

No payment for procedure

HIM and Coder Perspective

1. Establish routine lines of communication with radiologists– Hold 15-minute lunch and learns with “like”

group of radiologists• specific topic• explain what need• give real case examples with revenue impact


2. Get support from chief / lead radiologist3. Establish goals and provide incentives4. Standardize parameters for dictation5. Get radiology involved in your CDI

program

Communication


• Learn how to interact with others – Radiologists, referring MDs, technicians,

administrators, coders, and more• Hold combined meetings and talk about

coding

We Act Like Islands,But We’re Not

Radiology Administrator Perspective

• Know what is in your charge master, changes every year!

• Get support from HIM– Understand how HIM operates– Understand coding roles / process

• Understand reimbursement• Understand Local Coverage

Determinations (LCDs)

CDM Updates

• New CPT codes published annually in late summer or early fall– Must implement by January 1

• Includes:– Terminology updates (CPT 70496)– Deleted codes (CPT 74350)– New codes (CPT 49440)

• Level III codes updated bi-annually


• Establish radiology relationships and grow them– Include registration / business office too!

• Monthly reports back to radiology• Stay educated and on top of new

procedures

Professional Differences• Radiology coders vs. HIM coders• Different Focus• Different Training• And Payor Differences!

Radiology Today, “Clearing out the Cobwebs”, March 2008Online at: www.healthrecordservices.com/news

Different Focus

Radiology Coders HIM Coders Tips to Solve

Focus on diagnosis and reviews procedure codes

Focus on ICD-9-CM diagnosis. Focus on data for statistics and

quality reporting.

Lunch and learn for radiology coders about ICD-9-CM and

quality initiatives.

Limited outside review Under much scrutiny Both groups review OIG work plan and be aware of changes.

Procedure vs. Diagnosis Continued


Procedure coding can be automated. Radiology role is

to confirm / validate.

Can review all available documents to code diagnosis.

Employ trained, procedural coder in the radiology

department. Will probably code both diagnosis and

procedure.

Need ICD-9-CM code for medical necessity

Need ICD-9-CM code for medical necessity

Establish query process with radiologists.

Problem is usually ICD-9-CM diagnosis code for medical necessity. Radiology staff get caught in the middle!

Different Training


Focused, Specific training on radiology only Broad, general training

Encourage relationships between both sets of coders.

Combine educational offerings.

And Payer Differences!• Vary by region/insurance carrier• Reasons for denials include:

– Medical necessity (reason / justification for test)– Inaccurate CPT assignment– No and/or invalid modifier

• Denials managed post-billing by trained specialist or auditor

• Perform a pre-bill audit to decrease risk of denials (manual and automated edit process)


• Re-evaluate traditional loss-leaders• Educate techs and administrators• Work with referring physicians• Be more active in managed care contract

negotiations

Changing Codes and Reimbursement…What’s Coming in

2009?• For All: Medicare focused on reducing costs

– More bundling and more rules/edits for coding– Keep Medicare and OIG separate

• For Hospitals:– OIG will focus on inappropriate payment for x-rays in ED– Medicare payments for beneficiaries with other insurance

coverage– Recovery audit contractors (RAC)

• For Physicians:– Focus on over-billing and inappropriate payment

More Packaging • Bundling is when one service is a component of another

service– Example: 72132 CT of L sp with contrast includes

36000 injection of contrast

• Packaging = Services that Medicare deems separate but included in other services– Example: placement of an internal-external biliary

drainage catheter 47511 now includes the imaging guidance 75982.

Over the horizon…but be aware

• Recovery audit contractors (RAC)• Medicare OP quality measures

– Proposed measures for imaging efficiency• Other

Questions, Answers, Feedback

Dr. Auster: [email protected] Walk: [email protected]

Jeff Pilato: [email protected] Friedman: [email protected]

mailto:[email protected]

Radiology Coding

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