Coding and compliance tips and traps

October 01, 2021
By Melody W. Mulaik

Radiology administrators face a multitude of operational challenges daily. Arguably their least favorite item to address lies in ensuring compliant regulatory practices and accurate charge capture and coding for performed services.

While there are many regulatory concerns that must be monitored, the top three (3) issues are orders, the use of extenders and supervision. Ensuring accurate and complete orders match performed outpatient services is an ongoing and challenging issue. Proper use of, and billing for, radiology extenders is also of key importance. Finally, proper supervision of diagnostic services must be continually reviewed to ensure compliance.

Ensuring accurate charge capture and coding is challenging and does require staying up to date on new changes, but also validating that long time codes and processes are accurate. Each modality has unique concerns that must be continually monitored to ensure charges are not missed, codes are not assigned for services that are not appropriately documented, modifiers are accurately assigned and much more. This article will focus on a few of the coding tips and traps for breast imaging, ultrasound, CT, and MR, to encourage readers to create their own list of items to review and validate within their own organization.

Breast Imaging
Some of the key issues in breast imaging are ordering and documenting screening versus diagnostic mammograms, ensuring orders for ultrasounds, correctly documenting and coding for post procedure mammograms.

Medicare does not require a physician’s order for a screening mammogram. A diagnostic mammogram, like other diagnostic tests, must be ordered by the treating physician. There is an exception to the Medicare ordering rules for diagnostic tests that enables the radiologist to order a diagnostic mammogram if the patient’s screening mammogram is abnormal. Breast ultrasound must be ordered by the patient’s treating physician.

A mammogram performed following an ultrasound or MR percutaneous breast procedure is separately billable if documented appropriately.

The two biggest issues in Ultrasound are the documentation of complete versus limited studies and ensuring orders, documentation and medical necessity for duplex studies in additional to regular ultrasound studies.

A duplex study can be reported together with a nonvascular U.S. study of the same anatomic area if both studies are medically necessary and must meet the requirements for the CPT code in terms of technique and structures visualized. A duplex scan requires performance and documentation of both spectral and color Doppler. The radiologist should dictate separate reports for the two studies or — at a minimum — describe the studies under separate headings in the same report.

Primary concerns in CT relate to the billing of CT and CTA during the same encounter, and appropriately assigning 3D codes. In most cases it is not appropriate to report a CT code together with a CTA code for the same body area. In order for both exams to be billed, the CTA must involve a “new data acquisition” and there must be an order from the treating physician for both exams, both exams must be medically necessary, and both must be separately and completely documented.

The code assignment for 3D rendering depends upon whether the 3D postprocessing was performed on the scanner workstation (76376) or an independent workstation (76377). Code 76377 should not be assigned unless the radiology report indicates an independent workstation was used for the postprocessing. The 3D rendering codes require concurrent physician supervision of image postprocessing, 3D manipulation of the volumetric data set, and image rendering. If the 3D rendering is performed on a different date of service than the CT or MR scan it is still appropriate to submit 76376 or 76377 for the rendering of the 3D images.

There are few MRI coding concerns, and breast and prostate top the list for many organizations. The assignment of correct procedure codes is dependent on the location and payer. Medicare still maintains the C codes for the technical component (TC). Non-hospital TC contrast-only examinations should be reported with the unlisted code 76498 since there is currently no procedure code for this service. For patients with dense breast tissue in which an abbreviated breast MRI (AB-MRI) is performed for cancer screening, it is appropriate to bill either code 77048 or 77049. These codes were intended to be used for screening and diagnostic breast MRI.

Some imaging facilities use computer-assisted detection (CAD) software such as DynaCAD to evaluate prostate MR studies. There is no code for prostate MRI CAD. This service can be reported using the unlisted MRI procedure code, 76498 and the appropriate MRI pelvis code.

Melody W. Mulaik
This article highlights just a few of the issues that should continually be evaluated to protect your organization’s compliance and reimbursement. Correct coding and compliance are a journey, not a destination. While it may not make the short list of favorite things to address, it is important and can yield great rewards — figuratively and literally.

About the author: Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle Coding Strategies