During the 2018 Annual Clinical Coding Meeting presentation “Covering Your Assets: Avoiding Common Risk Areas in Diagnostic Radiology,” Stacie Buck, RHIA, CCS-P, RCC, RCCR, CIRCC, AAPC Fellow, president and senior consultant of RadRx, shared her vast knowledge of diagnostic radiology. Buck discussed topics that include Medicare requirements on test orders, how the rules differ from setting to setting, best practices to support medical necessity, and how to ensure documentation requirements are met to be able to identify high-risk areas.
At this physician/outpatient coding break-out educational track, Buck had a large crowd of attendees ready to learn more information about diagnostic radiology. She began her session by going over diagnostic tests and why there continues to be confusion about which diagnostic test coding rules are to be followed for the different setting involved—hospital vs. physician practice vs. independent diagnostic testing facilities (IDTF). Buck briefly reviewed each of these settings and some points of the Code of Federal Regulations (CFR), which helped the group start to understand some of the differences between them. To read and learn more on the areas reviewed, go to www.cms.gov and search for 42 CFR 482.26 Hospital Conditions of Participation (CoP) for Medicare, 42 CFR 410.32 Physician CoP for Medicare, and 42 CFR 410.33.
Buck stressed that having the core understanding of each setting will ultimately guide an HIM professional on what is applicable for their organization. Using the above Medicare rules as a resource to understand the requirements for diagnostic test orders will in turn ultimately help organizations achieve compliance in the event of an audit.
Buck stressed that the key area of “medical necessity” must be followed, and to also follow National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). “The coding professional needs to follow medical necessity and the healthcare services or supplies that are needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet the accepted standards of medicine,” Buck said. Buck pointed out that it is important to remember Medicare may only pay for items and services that are reasonable and necessary, and stressed the importance of reviewing the LCD requirements beyond the ICD-10-CM codes listed in the covered indications section to ensure all documentation requirements are met.
Buck covered some ideas on a key area for auditing. She went over the details on coding complete vs. limited ultrasounds, indicating that to code complete ultrasound a description of elements or the reason an element could not be visualized must be documented (for example: surgically absent, obscured by bowel gas, etc.). Buck also explained that limited ultrasound codes are used once per session, not per organ. In auditing these types of encounters, be sure to verify that the documentation substantiates a complete exam.
Buck reminded the audience that HIM professionals need to understand the basics of selecting a diagnosis code and how important the correct selection is, and recommended reviewing the ICD-10-CM Diagnostic Coding and Reporting Guidelines for Outpatient Services. All this knowledge leads up to reviewing the actual documentation. Buck explained that when reviewing the diagnostic radiology documentation, she takes a “bottom-up” approach. Review the Impression, then Clinical Indicators, following the coding guidelines. “It’s all about the clinical significance,” she said.
Buck shared a list of questions that coding professionals frequently ask because they find them to be confusing or hard to grasp, including:
- Can I code from the header of the radiology report?
- Must the body of the report support the exam stated in the header?
- Do I use the findings or signs/symptoms for coding?
- If the radiologist uses the phrase “consistent with,” can I code the condition?
- Is the phrase “evidence of” considered a definitive diagnosis?
- Many of the radiology reports that we code have MVA or trauma listed as the reason for the exam. What ICD-10 code should be assigned in these instances?
- When the reason for the exam is “pain” can I code the pain of the site being examined?
Buck covered a lot of material in her one-hour presentation. She mentioned that physicians like to see the rules and information to help them understand, and Buck urged the audience to also share all of this information with the physicians in their organizations.