Top 5 errors done by Radiology Medical coder

In radiology facility, the medical charts are very descriptive. Yes, there are certain specific information given in chart for coding correct CPT and ICD 10 codes.

As per my experience, the Technique, Reason for exam & the Conclusion (impression) are the main section of radiology medical charts to code them perfectly.

Now, to code a medical report with proper CPT, ICD 10 & HCPCS codes, coder need a have ask themselves few questions before finalizing the chart and sending it to billing.

Are Modifiers used correctly with CPT codes?

If you are coding for physician, the coder has to assign 26 or TC modifier depending on the documentation. For global code, no need to assign any modifier along with CPT code. Global code includes both 26 & TC components. The most common modifiers along with 26 & TC modifiers in radiology are 59, 76 & 77.

59 or X{EPSU} – for distinct procedure service

76 modifier – duplicate procedures on same day by same physician

77 modifier – duplicate procedure on same day by different physician

Also, LT & RT modifiers are used very frequently for coding extremity procedures.

For Medicare PET-CT scan, PI & PS modifiers are used for initial and restaging. These procedures are rare but important in radiology facility.

Incorrect or missing modifiers in claim can lead to denial of the claim, hence proper use of modifier is very important in medical coding.

Are the correct number views captured for the CPT code?

This is a very common mistake done by coders in radiology facility. If I share my experience, I have made lot of errors in counting number of views for chest x ray procedures.

Still many coders do not understand anteroposterior (AP), lateral (L) and oblique (O) views means how many views. After coding for few months, coders come to know than oblique views are calculated as two views, hence it is will to total four views (AP, L and O).

Chest x-ray’s procedures has a lot of different views which will help in understanding the views.

Do not compare views with images or films. The views are totally different from images or films. The number of images or films are not equal number of views.

“Fours images or films is not equal to Four Views”

Did you code correct CPT code with or without contrast?

CT or MRI exams are the most common procedure codes in radiology facility which used contrast. The CT and MRI exam are done to examine the soft tissues, which are visible in X-rays. Hence MRI and CT exams used contrast to examine the health of soft tissue in non-contrast and contrast exam.

Sometimes both without and with contrast MRI or CT exam is done to find out any abnormality in the soft tissues.

Do not consider oral contrast and intravenous contrast as same. The oral contrast exam should be always considered as without contrast exam. CT and MRI CPT codes without contrast should be used when oral contrast is used.

For intravenous contrast, always use with contrast CT or MRI CPT codes.

Even CTA, MRA procedures use contrast in their exam.

Always remember below points while coding contrast CPT codes

Oral or rectal contrast should be always reported with “without contrast” CPT codes. They do not meet the criteria for “with contrast” as per CPT coding guidelines.
Intravascular (vein or artery), Intra-articular (into a joint) or intrathecal (into the spine) contrast should be reported with “with contrast” CPT codes.

Coding of COVID-19 Diagnosis

Now due to coronavirus disease, their has been many new ICD-10 diagnosis added for COVID-19. During pandemic, most of the medical reports were related to COVID-19 diagnosis because their was large amount of screening or testing done to isolate the coronavirus carrier patient. But, many coders were commiting errors for coding the present and history COVID-19 diagnosis or use of screening or testing COVID-19 codes. So, medical coders should strictly follow the coding guidelines for COVID-19 ICD-10 codes to avoid any diagnosis errors.

Is Medical necessity is fulfilled?

While coding CPT and ICD 10 codes, it is very important that diagnosis codes fulfill the medical necessity for procedure code.

If ICD 10 codes, fails the medical necessity for CPT code, then there is the possibility of getting your claim to be denied. For Medicare payers, failed medical charts claim are not paid, hence reimbursement get affected.

Hence, while coding radiology charts check for the ICD 10 codes used along with CPT codes.

NCD (National Coverage Determination) and LCD (Local coverage determination) from CMS can help you get more information about importance of medical necessity.

Did you use most Specific ICD 10 codes?

ICD 10 are very specific. While reading the radiology report, we only focus on the conclusion to code the confirm diagnosis. But, the confirm diagnosis may be not documented specifically in the conclusion.

For example, in most of the CT abdomen & pelvis radiology reports, diverticulosis is reported in conclusion but when we read the finding of the report, it is specifically documented as colon diverticulosis.

Now, here diverticulosis leads to unspecified ICD 10 code, K57.90 while colon diverticulosis leads to specific ICD 10 code K57.30

Hence, coding more specific ICD 10 code help in proper payment and secure payment by the payers.

Hope, next time you will ask all these question to yourself before finalizing the radiology medical charts. This will surely help in improving your coding skills.

References:

https://www.outsourcestrategies.com/blog/2018/10/

https://www.radiologytoday.net/archive/rt1217p6.shtml