Diagnosis Coding Guidelines For Radiology Billing

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Diagnosis Coding Guidelines For Radiology
Billing
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Diagnosis Coding Guidelines For Radiology Billing

• Submitting a clean claim and bringing accurate
  reimbursement for radiology is a challenging task
  requiring billing and coding expertise. Although
  many claims are being paid when initially
  submitted, post-payment reviews by insurance
  carriers might result in returning the insurance
  reimbursements. All this can be avoided with
  proper documentation supporting medical
  necessity. With radiology services coming under
  intense scrutiny for medical necessity, it is
  more important than ever to ensure documentation
  supporting medical necessity. This includes
  ensuring that diagnosis coding is done in
  accordance with the official coding guidelines
  and the Center for Medicare Medicare Services
  (CMS) policy. Following diagnosis coding
  guidelines will support medical necessity
  ensuring insurance reimbursements while billing
  for radiology services.
• Diagnostic Test Order
• An encounter for radiology services begins with a
  test order from the referring (ordering
  physician) which is then taken to an imaging
  center, hospital, or another provider of
  diagnostic imaging services. A complete and
  accurate test order is crucial to coding
  compliance because payment for services by
  Medicare is made only for those services that are
  reasonable and necessary. Furthermore, CMS
  charges the referring physician with the
  responsibility of documenting medical necessity
  as part of the Medicare Conditions of
  Participation (42 CFR 410.32).
• The Balanced Budget Act of 1997 reiterates the
  above requirement in Section 4317(b) where it
  states that the ordering physician must provide
  signs/symptoms or a reason for performing the
  test at the time it is ordered. If the referring
  physician indicates a rule out, he/she must
  also include signs/symptoms prompting the exam
  for ruling out that condition.

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Diagnosis Coding Guidelines For Radiology Billing

• In the event this information is missing, the
  ordering physician should be contacted for this
  information before proceeding with the exam.
• Since medical necessity is determined by those
  signs/symptoms provided by the ordering
  physician, it is vital to have this information
  at the time of final coding even when the
  radiology report identifies an abnormal finding
  or condition. This information is key in helping
  to determine whether or not a finding is
  incidental or related to the presenting
  signs/symptoms.
• Furthermore, a test ordered to rule out a
  specific condition is considered a screening exam
  in the eyes of Medicare and would need to be
  coded as such in the absence of documented
  signs/symptoms, with a screening code assigned as
  the primary diagnosis and any findings assigned
  as additional diagnoses.
• Choosing the Primary Diagnosis
• As per ICD-10-CM official guidelines, for
  patients receiving diagnostic services only
  during an encounter/visit, sequence first the
  diagnosis, condition, problem, or other reason
  for encounter/visit shown in the medical record
  to be chiefly responsible for the outpatient
  services provided during the encounter/visit.
  Codes for other diagnoses (e.g., chronic
  conditions) may be sequenced as additional
  diagnoses. For encounters for routine
  laboratory/radiology testing in the absence of
  any signs, symptoms, or associated diagnosis,
  assign Z01.89.

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Diagnosis Coding Guidelines For Radiology Billing
If routine testing is performed during the same
encounter as a test to evaluate a sign, symptom,
or diagnosis, it is appropriate to assign both
the Z code and the code describing the reason for
the non-routine test. For outpatient encounters
for diagnostic tests that have been interpreted
by a physician, and the final report is available
at the time of coding, code any confirmed or
definitive diagnosis(es) documented in the
interpretation. Do not code related signs and
symptoms as additional diagnoses. Radiology
Report While the test order may determine medical
necessity and initially drive the encounter, a
review of the final radiology report holds the
key to determining the correct diagnosis codes
for an encounter. Radiology reports should
contain four main sections clinical indications
technique summary of findings and impression
and final interpretation. The clinical
indications listed on the report should be those
signs or symptoms provided by the referring
physician that prompted the ordering of the test.
The radiologists final interpretation, the
impression, may list multiple conditions and is
the final piece of the puzzle in choosing a
primary diagnosis code. Additionally, a careful
review of the clinical indications will help
determine whether or not certain conditions
mentioned in the findings section, or in the
impression, are clinically significant or simply
incidental findings.
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Diagnosis Coding Guidelines For Radiology Billing

• Documentation for Diagnosis Code
• At first glance it may appear that diagnosis
  coding for diagnostic radiology exams is
  straightforward, it actually can be quite
  challenging. In many cases, the documentation
  that must be reviewed prior to assigning a
  diagnosis code may be unavailable, unclear, or
  contradictory. There are two key documents for
  review. Although each is a viable source document
  for selecting a diagnosis code for the encounter,
  utilizing only one of these two documents to
  select procedure and diagnosis codes can result
  in unnecessary coding compliance risks for any
  provider of services.
• Test order with accompanying signs/symptoms
• Radiology report containing the final written
  interpretation
• Accurate selection of diagnosis codes and
  following coding guidelines will ensure steady
  insurance reimbursements in radiology billing. If
  you need any assistance in medical billing and
  coding for radiology billing, we can help.
  Medisys Data Solutions Inc. is a leading medical
  billing company that is well versed with billing
  policies and coding guidelines for radiology
  billing. To discuss your radiology specific
  billing requirements, contact us at
  info_at_medisysdata.com/ 302-261-9187

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