On June 21, 2011 we provided you with 6 very easy ways to increase and maintain revenue, while improving documentation compliance. Here is Part 2, tips 7 thru 12. Consistent use of these tips can significantly improve your revenue cycle management process, reduce denials and administrative costs, while simultaneously reducing your chances of a costly government audit.
7. Helpful Hints for ICD-9 Diagnosis Coding:
* Any and all associated signs and/or symptoms should be provided in dictation. When exams are found to be normal the coder refers back to reason for exam to process claim for reimbursement.
* It is recommended to have a dictated history/reason for exam. Although the ordered history is often available for coding purposes, unless it is part of the dictation, it would not be considered part of the dictated report, which is the source legal document of the exam performed.
* Terms such as “Fall”, “R/O DX”, & “MVA” do not provide specific diagnostic information and cannot be used for coding purposes.
8. Per the American Hospital Association’s Coding Clinic, language such as “consistent with” and “compatible with” fall into the same category as “probable”, “likely”, and “possible” and would not be considered a definitive diagnosis. Similar language that would not be considered definitive is “can be associated with”, “questionable” and any comparative language (“A vs. B”). It is important to dictate to the highest level of specificity and to refrain from using this language if a diagnosis is confirmed.
9. If a patient is returning as a follow up from a prior OB ultrasound for re-evaluation of fetal size or for follow up of a suspected abnormality, it must be documented in the radiology report. If the coders are unaware that it is a follow-up study, there is potential for erroneous coding.
10. For a complete OB ultrasound <14 weeks, the following MUST be documented:
* Number of gestational sacs and fetuses.
* Gestational sac/fetal measurements appropriate for gestation.
* Survey of visible fetal and placental anatomic structure.
* Qualitative assessment of amniotic fluid volume/gestational sac shape.
* Examination of the maternal uterus and adnexa.
Note: Documentation of the reason for non-visualization of any specific element is sufficient for a complete study.
11. CPT codes for non-invasive physiologic studies underwent revisions for 2011. Specifically, please note the following code revisions for studies of the extremity arteries:
* 93922-Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels)
* 93923-Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia)
The key change for 2011 is that 93922 was previously used for single level only. With the revision, the limited study encompasses one OR two levels and the complete should only be used if analysis is performed at 3 or more levels. Documentation of each level studied is imperative for proper CPT code selection and to ensure maximum reimbursement.
12. A complete female transabdominal pelvic ultrasound (76856) includes the complete evaluation of the female pelvic anatomy. If all elements are not documented in the report, it would be down coded to a limited study. If the reason for non-visualization of an element is documented, it would still be considered a complete study. The following elements must be documented:
* Description and measurements if the uterus and adnexal structure.
* Measurement of the endometrium.
* Measurement of the bladder (when applicable).
* Description of any pelvic pathology (e.g. ovarian cysts, uterine leiomyomata, free fluid, etc.)
With best regards,
Jennifer Bash, RHIA, CPC, CIRCC, RCC
Senior Coding Specialist