All medical specialties utilize the Current Procedural Terminology (CPT) that is published and maintained by the American Medical Association (AMA). This manual contains thousands of five-digit codes that are used to report medical services in a universal language understood by certified professional medical billers, medical coders, and medical documentation specialists. Physicians and other health care providers normally perform the same kinds of procedures over and over, and they are only familiar with the codes they usually assign to these procedures. Radiologists, for instance, bill for most of their services by using codes 70010 through 79999.
Even within the 70000 series code set, there are numerous sub-sets of codes used to describe the specialties within radiology, including nuclear medicine and diagnostic ultrasound. No radiologist uses every available code on a regular, or even an irregular basis. The roughly 10,000 codes defined to describe radiology services are too many for a physician to learn in addition to treating patients.
Like healthcare providers, medical billing professionals tend to specialize in one area of expertise. Radiology medical billers are familiar with all the aspects of radiology coding. They understand the difference between the technical component of a service (billed with a modifier -TC) and the professional component (billed with a modifier -25). They understand when component services need to be bundled into a more extensive procedure, and they understand when services can be billed during the same encounter, and how to modify the codes to receive appropriate payment.
CPT contains very precise descriptions for every code it contains. The AMA CPT board is composed of physicians and health care industry professionals. The board reviews current codes and compares them to current medical practice. When a new procedure becomes commonplace enough to be billed to insurers on a regular basis, the AMA adds codes to the CPT manual. As codes become obsolete, because the procedures are no longer performed on a regular basis, the AMA deletes codes from CPT. Codes are amended annually to ensure that the procedure described by a particular code accurately reflects the service provided. There are thousands of CPT codes. If a procedure is part of current medical practice, it has a code to describe it.
Sometimes, a radiologist who concentrates on one radiological specialty, covers for a colleague in another specialty. The first radiologist is licensed to perform any medical procedure, and he is credentialed to perform any radiologic procedure. When he performs procedures that are not within the CPT subsets he normally uses, he may submit an unlisted radiology code for billing purposes.
A certified medical biller knows to be suspicious of any submitted CPT code that ends in 99. This means that there is no other code to describe the service provided. The procedure is unlisted in CPT.
An experienced medical biller knows that a bill containing the code 76499, Unlisted diagnostic radiographic procedure, means the claim will be denied with a request for records. An experienced medical coder knows that of the many codes used to describe diagnostic radiographic procedures, there is probably one that will match what the radiologist performed. An experienced medical documentat specialist will know that the patient’s medical record will contain the language to assign an accurate and correct code, ensuring a clean claim is submitted for reimbursement. When radiology specialty billers, coders and auditors work together, they correct claims quickly and effectively, increasing a radiology practice’s fiscal bottom line.
Unlisted radiology codes should be avoided when submitting claims to insurers for payment. If a radiology procedure is part of the currently established standard of care, there is most likely a CPT code to describe it. Billing unlisted radiology CPT codes slows down the reimbursement process with inappropriate coding methodology that can increase scrutiny from third-party payers, including Medicare. That increased scrutiny may result in a RAC audit to determine if a radiology practice codes all of its services appropriately.