The Devil Is in the Details

When it comes to getting paid for their services, the first goal for radiologists should be to document all they do, and document it without ambiguity or generalization.

The requirements of individual current procedural terminology (CPT) codes are specific, and only documentation meeting those requirements is eligible for full reimbursement. Let’s take a look at some of the most commonly underdocumented, or ambiguously documented, procedures in radiology.

Name Every Organ or Body Part

A radiologist performs a complete bilateral duplex scan of the lower extremities, but his medical record reads, “Right and left lower extremities performed with attention paid to the common femorals through the popliteal veins”.

In order to report a complete bilateral duplex ultrasound scan of the extremities, (93970) all of the following veins must be enumerated in the medical record for a lower extremities study: common femoral, superficial femoral, proximal deep femoral, greater saphenous, and popliteal veins. If any of the above listed veins is omitted from documentation, the service must be reported as a limited study (93971).

For a radiologist practicing in Fort Lauderdale, Fla., Medicare reimbursement drops by $72, from $198 to $126, when a limited exam in 93971 is reimbursed rather than the complete study in 93970. For a practice performing three under-documented complete scans a day, this omission will cost nearly $20,000 a year.

The same codes report duplex scans of the upper extremities. The following veins must be documented for the upper extremities to report a complete bilateral study of the upper extremities: subclavian, jugular, axillary, brachial, basilic, and cephalic veins. If all of these are not documented, this becomes a limited study. The record must also identify the study as bilateral in order for 93970 to be reported.

To report a complete abdominal ultrasound, CPT guidelines require grayscale-image documentation of nine components: liver, spleen, gallbladder, extrahepatic biliary tree, pancreas, kidneys (bilateral), upper-abdominal aorta, and inferior vena cava. For instance, a complete study in Los Angeles will pay $159, while a limited study pays $118.

Neglecting to include all nine organs when documenting a complete study costs the provider $41 when the complete study, reported with 76700, must be downcoded to a limited one (76705). Typically, 76705 reports a study of either a single organ, a limited area of the abdomen, or a single quadrant (i.e., right upper quadrant).

Another common omission is under-documenting retroperitoneal ultrasounds. CPT code 76770 reports a complete service, requiring documented examination of images of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava.

However, when the examination is done to evaluate urinary tract pathology, a complete retroperitoneal examination would consist of the urinary tract, including the kidneys and urinary bladder.

Commonly, when the test is ordered for urinary review, documentation is missing on the bladder or kidney, therefore, making this a limited exam (76775). The complete service reimburses at a rate of $122 in Ohio, while the limited one pays only $95. 

Be Specific in Diagnostic Descriptions

While most physicians consider CPT codes to be the “money codes”, payers want evidence of medical necessity before they will reimburse a procedure. Without demonstrating medical necessity, a claim will be downcoded or denied. That means ICD-9-CM codes have become money codes, too, in today’s medical business environment.

Professionals should place more focus on diagnostic coding, especially in radiology practices. Frequently, radiology documentation will mention “trauma” without describing any injury. Without specifying the site of injury or reporting any other findings, the coder can only document the ICD-9 code of V71.4, which means “observation following other accident”.

This code may be too vague for some payers, so radiologists should query the patient or the referring physician to determine the nature of the injury. Also, it is important to note any presenting symptoms, such as swelling or pain, to document medical necessity.

Another common diagnostic problem arises when the radiologist is asked to “rule out” a condition, or evaluate a “probable” condition. Neither of these phrases can be codified with ICD-9-CM, unless they are confirmed. So, how can medical necessity be demonstrated in scenarios in which the suspected condition is not confirmed?

They must be able to rely on the referring physician’s notes, and if no further information is available, it is the radiologist’s responsibility to query the patient about the reason for the test – for instance, a cough and fever (rule out pneumonia); fall with pain and swelling in hand (suspected fracture); or sudden unilateral swelling in leg (probable deep-vein thrombosis).

The symptoms can be codified, and demonstrate the medical necessity of the diagnostic tests. When results are sketchy, and the radiologist documents results as “consistent with” or “suggestive of”, these diagnoses are considered unconfirmed, and cannot be reported on the medical claim.

In these cases, as with “rule out”, radiologists should document symptoms thoroughly so medical necessity can be established in the claim. One key aspect of diagnostic documentation: The devil is in the details. Radiologists should check with coding staff to determine if there are specific diagnoses that require more specificity than they are providing.

For example, in femur fractures, the documentation must include the site of the fracture (femoral neck, shaft, or distal femur). Also, some tests are performed for reasons that may seem obscure or unimportant, but they can be pivotal in reimbursement – urinary tract ultrasound, for example, due to symptoms of nausea and vomiting.

Consistency Is Key

Simply specifying which procedure the physician is performing in the order or header is not sufficient; the documentation that follows must support that information.

For example, if an order reads “Two-View Chest AP and Lateral”, but the documentation in the body of the report only cites the performance of an anterior posterior, the coding staff will either downcode the claim to “one-view” or approach the physician for clarification. Sometimes, the order or header may lead to upcoding.

If an order states a CPT abdomen and pelvis with contrast was performed, and no further details are provided, the coder is left wondering whether the contrast was oral, which is included in the CT, intrathecal, or intravascular, which changes the CPT code to a higher relative value unit and allows for reimbursement of the separately coded contrast material.

To reduce ambiguity, the type of contrast (oral, intravenous, etc.) should be noted in the order.  Similarly, it is common for an order to identify “screening mammogram”, followed by a notation of a symptomatic breast lump or breast pain. Coding rules exclude any symptomatic patients from “screenings”; these patients would be receiving “diagnostic” exams instead.

Consistency is required to report the appropriate CPT code and ICD-9 code for either a screening or diagnostic test.

Another common documentation error occurs when an independent workstation is used for postprocessing of 3-D reconstructions, yet this fact is omitted. Regarding ultrasound guidance, CPT guidelines state, “Ultrasound guidance procedures require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which guidance is utilized.”

Another common documentation error is the failure to document the catheter access point to allow for appropriate ordering of vessels. Documentation must include every vessel that was selectively catheterized and imaged to report the appropriate radiology supervision and interpretation code.

Remember Teamwork

At times, it may seem like queries from medical coders are unrelenting and hair-splitting, but it’s important to remember that they are working in their physicians’ best interest. They want physicians to get paid for all they do, and they want to reduce compliance risks, too. It’s a challenge to be effective with both.

If a physician is spending too much time clarifying or reworking documentation, he may want to have his coding staff develop some “cheat sheets” of documentation guidelines, as well as pick up his CPT book and familiarize himself with the codes, descriptions, and guidelines therein.

A physician’s clinical understanding of CPT, combined with his coders’ knowledge of government and private payer rules and compliance guidelines, can improve the bottom line and reduce compliance risks. It’s a goal worth pursuing.


— Nicole E. Crawford, CPC, CCS-P, CCP, CCP-AS, RCC, works for Bethesda, Md.-based CodeRyte Inc. (www.coderyte.com) and has 17 years of medical coding and billing experience. She is a member of the American Academy of Professional Coders. Questions and comments can be directed to editorial@rt-image.com.