Did you ever think the words “hemorrhaging” and “vulnerable” would pertain to your radiology coding and billing? More than likely, they do. That’s because your healthcare revenue cycle management is actually more susceptible to errors which, when you add them up, can cost as much as a full time radiology coding professional on average.
It’s a fine line radiologists walk every day. Under-coding leads to lost revenue, while over-coding threatens compliance. The most common challenges stem from either inadequate documentation, which leaves coders without all the details necessary to maximize radiology reimbursement, or incomplete knowledge of latest coding practices.
Poor and inconsistent documentation opens the floodgates to coding errors and lesser CPTs, resulting in denials, delayed payments and increased compliance risks. One primary example is obstetric ultrasounds. The amniotic sac is the most commonly missed element. Although it is separate from the gestational sac, both are required in the documentation. As is true for all ultrasounds, if any organ or element can’t be visualized, a clear explanation needs to be included.
Your radiology practice is focused on providing the very best care, but inadvertently, a busy radiology tech might just miss the charge capture updates needed to reflect a change in patient procedures or supplies. You may interpret an exam using a different procedure name or view counts, or may not have the documentation to support coding for a specific procedure even though the procedure was, in fact, completed. This often leads to lost or under-coded charges and a greater risk of compliance problems.
Add to that the looming ICD-10 transition that requires a deeper understanding of the building blocks of diagnosis than ever before and heightened awareness of concise documentation.
The following steps are recommended to help improve documentation and reimbursement for diagnostic radiology healthcare revenue cycle management:
- Exam titles should never be listed in the findings section or impression.
- Clinical indications should be listed separately from the findings and impression.
- Exam titles should have all elements for correct code assignment, including modality (eg, MR, ultrasound, CT, X-ray), anatomical site, views and whether contrast was used.
- Exams should be succinct—for example, upright, oblique, decubitus views of the abdomen CT chest with and without contrast.
- Exam and clinical indication should be void of ambiguous, nonspecific, or unfamiliar terms or abbreviations. Avoid phrases without necessary descriptors, such as abdomen complete or abdomen series, or pulmonary embolism study.
This raises the question of just how involved a radiologist should be in the radiology billing and coding process. Coding isn’t just limited to the coding staff. Physicians are ultimately responsible for the codes submitted and the final documentation, hence it’s vital for physicians to have and maintain a working knowledge of CPT code requirements. Too often the dictated note does not match or clearly support the ordered exam title, forcing coders to make assumptions using incomplete data or take the time to pursue the physician for clarification.
Note: It’s a good idea for radiologists to dictate a title even if one is already provided in the order or by a technologist. Important to note is that reported CPT and ICD codes should not be coded from the orders or facility-entered data.
It’s time to stop the bleeding. To ensure your free flow becomes your revenue stream instead, niche expertise in outsourced radiology coding, billing and compliance is required anymore to optimize reimbursement. As your revenue assurance staff, revMD.com partners with radiologists to ensure they maintain control of radiology revenue cycle management.
revMD.com is the results-proven alternative for healthcare revenue cycle management, with a niche specialization in radiology billing and coding that generates unprecedented results and builds profitable medical practices. Leveraging a history of industry wide success spanning 26 years, revMD.com partners with medical practices throughout the U.S. to optimize revenue for hospital based and community based physicians. For more information, visit www.revmd.com.