Below are 6 very easy ways to increase and maintain revenue, while improving documentation compliance. 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.
1. The ACR recommends including the number and type of views in the report header for all diagnostic x-ray studies. This documentation is imperative. If there are separate CPT codes for different combinations of views (e.g., chest & spine x-rays) or different numbers of views (extremity x-rays), the radiology report must indicate which combination or number was performed. If the views are not documented, the coder must choose the lowest number of views which could result in down coding and a loss of revenue.
2. If procedures can be performed without contrast, with contrast, or without contrast followed by with contrast images, the report header must specifically describe what was performed. The American College of Radiology recommends including the concentration, volume, and route of contrast administration when applicable.
3. The American College of Radiology recommends that each dictated report contains the following information: Patient Information/Demographics, Clinical Indication, Report Header, Report Body including technique and findings, and a Final Impression.
4. With the introduction of codes 76376 and 76377 and the deletion of 76375 in 2006, 2D reconstruction has essentially become an unbillable service and considered part of the procedure. However, complex 3D image rendering often requires extensive independent workstation processing by a supervising physician and specially trained technologist, and therefore warrants a separate code. The following verbiage should be documented to support billing for 3D Reconstruction:
a. 3D rendering and post processing WAS reviewed on an independent workstation. (76377) or
b. 3D rendering and post processing performed on CT scanner NOT reviewed on an independent workstation. (76376) It is important to note that 3D rendering is now a requirement in order to code a CTA.
5. In order to bill for a diagnostic noninvasive vascular ultrasound (“Duplex study”), the following information needs to be documented:
• B-mode or 2D gray scale imaging of the vascular structure AND
• Doppler spectral analysis and color
If both are not documented in the radiology report, it may result in down coding and have a negative impact on reimbursement.
6. The ACR and AMA agree that radiologists should properly identify separate procedures in a report. If separate, distinct, and complete studies of different body sites are performed, then each study should be dictated in separate reports or under separate headings within one report. This will help coders identify all procedures performed and ensure that radiology practices are not disadvantaged during an appeal or audit.
With best regards,
Jennifer Bash, RHIA, CPC, CIRCC, RCC
Senior Coding Specialist