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Coding and compliance tips and traps

October 01, 2021
Business Affairs X-Ray
From the October 2021 issue of HealthCare Business News magazine

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.

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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.

Ultrasound
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.

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