This blog first appeared on RadRx.
One of the areas that present the greatest risk for providers of radiology services is incomplete documentation. Although providers may be coding correctly for the services rendered, often the radiology report does not have adequate documentation to substantiate services that were billed.
Most post-payment reviews of radiology claims involve sending medical records to a payer or auditor. Their determination is based on what is documented on paper because they do not have access to the actual images taken during the study.
The following list summarizes common documentation deficiencies for diagnostic radiology exams. While some of these items may seem basic, it is surprising a large number of radiology reports contain these deficiencies.
It extremely important to educate your radiologists on the importance of complete documentation and what is required for the various types of exams.
7 Common Documentation Deficiencies for Radiology Exams
1. The number and types of views are not documented in the body of a report.
It is important to document the number and types of views in the report to ensure that the correct code is captured for the encounter.
Additionally, the header of radiology reports is often populated based on order entry, so it may not accurately reflect those organs/anatomical regions actually viewed and interpreted by the radiologist. If the number and types of views are not documented, a claim may be downcoded.
2. Use of contrast material and type of contrast material is not documented in the report.
It is highly recommended that this information is included in the body of the report for the exam. Correct CPT code assignment is dependent upon documentation of the use of contrast.
It is also important to clearly document without contrast sequences and with contrast sequences in the report. When contrast is administered the route of administration, type of contrast and amount administered should be documented in the report.
The phrase "with contrast" is utilized in the descriptor of many radiology CPT codes, in particular in MRI and CT code descriptions. This phrase represents contrast materials that are administered intravascularly, intra-articularly and intrathecally. Studies that utilize oral contrast or rectal contrast alone do not represent “with contrast” studies for coding purposes.
This information is also important for the facility that is billing for the contrast material since there are specific HCPCS codes to be billed based on the type and even concentration of the contrast material and these codes are billed in multiple units.
3. Coding for ultrasound and duplex studies during the same session
It is important to exercise caution when billing an ultrasound and duplex study of the same anatomical area during the same session. The NCCI Manual Chapter 9 says:
"Abdominal ultrasound examinations (CPT codes 76700-76775) and abdominal duplex examinations (CPT codes 93975, 93976) are generally performed for different clinical scenarios although there are some instances where both types of procedures are medically reasonable and necessary. In the latter case, the abdominal ultrasound procedure CPT code should be reported with an NCCI-associated modifier."
The ultrasound exam is considered bundled into the duplex exam when the two studies are not separate and distinct and medical necessity is not documented for both.
Here are some additional items of importance concerning coding and documentation of duplex studies:
In the Radiology section, CPT states: "Evaluation of vascular structures using both color and spectral Doppler is separately reportable. To report, see Noninvasive Vascular Diagnostic Studies (93875-93990). However, color Doppler alone, when performed for anatomic structure identification in conjunction with a real-time ultrasound examination, is not reported separately."
In the Medicine section, CPT states: "Duplex scan (eg, 93880, 93882) describes an ultrasonic scanning procedure for characterizing the pattern and direction of blood flow in arteries or veins with the production of real-time images integrating B-mode two-dimensional vascular structure, Doppler spectral analysis, and color flow Doppler imaging." (CPT 2018, Professional Edition, American Medical Association)
The ACR's Economics Committee on Coding & Nomenclature and the ACR's Economics Committee of the Commission on Ultrasound have taken the position that to assign these codes both spectral and color Doppler should be performed. (2017 Ultrasound Coding User's Guide, American College of Radiology)
A true vascular analysis must be performed—the use of Doppler simply to determine whether or not a structure is vascular does not constitute vascular analysis. A full and complete color Duplex with waveform analysis must be performed.
In the Ultrasound Coding User's Guide ACR specifically states "Assessing flow with color, recording a waveform and reporting the findings in a medically indicated examination are the key elements to look for in a report." In the report there should be documentation of the velocity measurements of blood flow with phrases such as "waveform normal", "spectral Doppler showed no flow" or "normal triphasic waveform patterns using Doppler interrogation".
4. Documentation for 3D Reformatted Images
The key to correct code selection is determining the method in which reformatted images are obtained.
Code 76376 and 76377 are not to be utilized to report reformats constructed from axial images:
- coronal
- sagittal
- multiplanar
- oblique
Codes 76376 and 76377 represent complex renderings including:
- shaded surface
- volumetric rendering
- quantitative analysis (segmental volumes and surgical planning)
- maximum intensity projections (MIP)
It is also important to note that medical necessity must be documented for obtaining 3D reformatted images. 3D reformatting, should not be standard protocol for MRI and CT exams.
5. CTA Documentation
To code for a CTA exam, a report must reflect that the image post-processing consisted of 3D reformatting to submit the CTA codes. The following is from the May/June 2009 issue of ACR Coding Source:
Two-dimensional (2D) post-processing does not constitute a computed tomographic angiography (CTA) study. When CT scanning is performed using contrast enhanced dynamic-timed imaging and 2D reformatted axial images are obtained or multiplanar reconstructions (MPR) (e.g., coronal, sagittal, or even an off-axis view) are done, this should be reported with a standard CT with contrast code that identifies the anatomic area studied. None of these 2D planar reconstructions qualify as “angiographic” reconstruction.
As noted in the Fall 2008 issue of Clinical Examples in Radiology, Computed Tomography Angiography is a distinct type of service that includes postprocessing for angiographic reconstructions. In order to report “angiographic reconstructions”, the physician needs to use different techniques which can all broadly be classified as 3D techniques. These include maximum intensity pixel (MIP) reconstruction, volume-rendered images, or other 3D techniques. If a referring physician orders a CT study for a vascular indication and the radiologist feels a CTA study is clinically indicated, appropriate documentation of the medical necessity for the CTA is strongly recommended.
6. MRI of the Brain & Orbits
When these two exams are performed during the same session, they must be separate and distinct exams and medical necessity must be documented for each to report both. The NCCI Manual Chapter 9, number 18 says:
"An MRI study of the brain (CPT codes 70551-70553) and MRI study of the orbit. (CPT codes 70540‐70543) are separately reportable only if they are both medically reasonable and necessary and are performed as distinct studies. An MRI of the orbit is not separately reportable with an MRI of the brain if an incidental abnormality of the orbit is identified during an MRI of the brain since only one MRI study is performed."
7. Ultrasound – Complete vs. Limited Studies
It is not sufficient to have an exam titled as a complete ultrasound study since CPT has explicit guidelines to follow when coding ultrasound studies. All required elements must be documented to code for a complete exam – if even one element is missing the exam must be coded as a limited ultrasound exam.
A common documentation deficiency for complete abdominal ultrasounds is the failure to mention the IVC. CPT-4 requires the following elements to be documented to code for a complete abdominal US:
"A complete ultrasound examination of the abdomen (76700) consists of real-time scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality."
"If less than the required elements for a "complete" exam are reported (eg, a limited number of organs or limited portion of region evaluated), the "limited" code for that anatomic region should be used once per patient exam session." (CPT 2018, Professional Edition, American Medical Association)
Other ultrasound exams that are often coded incorrectly are retroperitoneal ultrasounds. CPT states:
"A complete ultrasound examination of the retroperitoneum (76770) consists of real-time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality. Alternatively, if clinical history suggests urinary tract pathology, a complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound." (CPT 2018, Professional Edition, American Medical Association)
Remember, all required elements must be documented to code for a complete exam. It is also important to note that an ultrasound for the kidneys and bladder, when performed for urinary pathology, is considered a complete retroperitoneal exam, code 76770, rather than codes 76775 (limited retroperitoneal) and 76857 (limited pelvic exam).
This blog post first appeared on RadRx.
Stacie L. Buck, RHIA, CCS-P, RCC, CIRCC, AAPC Fellow
President & Senior Consultant, RadRx