‘If it’s not dictated, it didn’t happen’

Strong documentation is the key to good coding. Without accurate clinical notes, compliance risks increase and reimbursements are reduced. ReveNews recently spoke with McKesson certified coders about common documentation errors in radiology.

Old habits die hard, especially when it comes to radiology documentation, according to Laura Roe, CPC, a radiology coding manager for McKesson Business Performance Services (McKesson).

“Some physicians – particularly ones who have been practicing for a while – can be pretty set in their ways when it comes to dictating radiology reports,” she said. “They have their own verbiage, and no matter how much feedback you provide, they will keep making the same mistakes over and over again. It’s unfortunate, because it costs time and money to resolve the issue through requests for additional information (RAI).”

As important as accuracy is in today’s environment, detailed and precise clinical notes will become even more essential once the ICD-10 code sets take effect in October of this year, she added. ICD-10 documentation requires far greater clinical and anatomical specificity than the current ICD-9 system.

“To code correctly, coders need the entire picture,” Roe said. “Physicians need to remember that accurate and timely reimbursement depends on good documentation, and that if it’s not dictated, it didn’t happen.”

Roe identified some common diagnostic and interventional radiology documentation errors.

Diagnostic Radiology:

  1. Insufficient documentation or vague terminology when describing the number of x-ray views. Terms such as “multiple views,” “projections” and “images” are often used instead of the specific number and type of views. But these terms do not constitute accurate descriptors as required to assign a CPT. Physicians instead should rely on the CPT manual code descriptions for accurate documentation. 
  2. Failing to document the use of ultrasonic (US) guidance for vascular access. Frequently, the radiologist mentions only that US guidance was used to access a vein for central line placement or other diagnostic or procedural purpose. Per the CPT rules, documentation of vessel patency and needle access into vessel also must be dictated. A documented hard copy of the access is additionally needed for billing CPT code 76937.
  3. The teaching attestation by the attending radiologist is either missing or insufficient for hospitals that have radiology residents.
  4. Documentation is missing for ultrasound exams that have organs or anatomical areas that must be documented in order to assign a “complete” ultrasound CPT code. This includes abdomen ultrasound (nine organs need to be documented), extremity ultrasound (documentation of the specific joint must include muscles, tendons, soft tissue structures and any other abnormality), and per this year’s CPT changes, ultrasound of the breast (all four quadrants of the breast and retroareolar region, including axillary area, if imaged).

Interventional Radiology

Documentation is frequently insufficient for billing a diagnostic image prior to a therapeutic procedure, per the guidelines set forth in the CPT manual. CPT specifically states that:

  • Diagnostic angiography/venography performed at the time of an interventional procedure is separately reportable if:
    • No prior catheter-based angiographic study is available and a full diagnostic study is performed and the decision to intervene is based on the diagnostic study, OR
    • A prior study is available, but as documented in the medical record:
      • The patient's condition with respect to the clinical indication has changed since the prior study, OR
      • There is inadequate visualization of the anatomy and/or pathology, OR
      • There is a clinical change during the procedure that requires new evaluation outside the target area of intervention. 
    If diagnostic angiography is necessary and it is performed at the same session as the interventional procedure and meets the above criteria, modifier 59 must be appended to the diagnostic radiological supervision and interpretation code(s) to denote that diagnostic work has been done following these guidelines:
  • Bundling the amount of views on close anatomical x-rays, rather than separating each anatomical area (i.e., “six views of right ankle/foot or hand/wrist). This can’t be coded correctly because it doesn’t specify the exact number of views for each anatomical area imaged.
  • For Medicare patients, a secondary diagnosis is required for all pre-operative chest exams (the underlying condition that the patient is having the surgery for) and for exams that have LCD (Local Coverage Determination) requirements for the secondary diagnosis for medical necessity, such as vertebral augmentation, CT Colonography and DXA scans.
  • Using only the terms “fall” or “trauma” as a reason for an exam. These terms are deemed insufficient to assign an injury ICD code by the AHA (the organization that writes the rules for ICD coding). The AHA requires that an observation ICD code, such as V71.4 Encounter for examination and observation following accident, be includedwhen “fall” or “trauma” is used as clinical indications.

About the author

McKesson Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.