The golden rule for medical billing has always been "If it's not documented, it wasn't done." For diagnostic imaging centers, that's especially true, where accurate reimbursement hinges on extremely precise documentation and coding.
And if you're not getting it right, you're leaving money on the table—in the form of denials and underpayments, not to mention staff hours reworking claims for insufficient or incorrect documentation.
Here are a few of the most common mistakes holding up your reimbursement for diagnostic imaging services:
1. Not documenting the actual number and specific views in a study.
A knee exam has four different CPT codes based on the number and type of views—and if you aren't documenting the precise number and/or specific views, you have to code to the lowest level. It's not enough for your office to have a list of standard views for each exam, the imaging report must specify what was done so that the coder can choose the proper codes. "Four views of the knee" is acceptable language in the medical report, but it's even better if the radiologist can give details, such as "AP, lateral, and both obliques" to support the CPT code. Remember, the key is number of views and not the number of films.
2. Omitting essential components in the imaging report.
The American College of Radiology requires that all imaging reports include the following information in order to be complete:
- Exam name
- Clinical indication/reason for exam
- Description of exam, sequences, and/or technique
- Comparison studies if applicable
- Conclusion and recommendations, if indicated
- Physician's signature
Other essential components from a coding perspective include laterality where applicable and details such as whether the study is a repeat of a prior study. Skip any one of these elements and your reimbursement can be delayed or reduced.
3. Failing to distinguish and document scout films.
A supine abdomen or scout KUB is typically performed with an upper GI series and in order to support the correct code, the KUB and findings must be dictated separately from the upper GI. Simply saying "Preliminary films were obtained" does not meet documentation requirements.
Similarly, an esophagram is typically bundled into the upper GI series, but in some cases, multiple views or a cine esophagram may be performed. If the documentation supports medical necessity for the separate esophagram, it can be coded separately with a modifier -59.
4. Not documenting every component of a "complete" ultrasound exam.
There are strict criteria for what constitutes a complete abdominal ultrasound or renal ultrasound, and each organ or structure must be documented in the medical report to justify the "complete" code. If any anatomical structure is missing, you must down-code to a limited study. Don't forget that there must be a permanent record and measurements for diagnostic ultrasound studies.
5. Incompletely or incorrectly documenting and coding contrast studies.
CT scans and MRIs are only considered contrast studies if the contrast is administered intravenously; oral and rectal contrast doesn't count as a contrast study. Beyond that, make sure the documentation accurately reflects whether the study was performed without IV contrast, with IV contrast, or without followed by with contrast. Keep an eye on coding parentheticals to look for additional coding opportunities on contrast studies.
Related Article: How to Reduce Denials and Rejections in Radiology Billing
Don't forget to document type and amount of contrast for HCPCS coding.
6. Not documenting nuclear medicine and PET supply kits.
Radiopharmaceuticals are not included in diagnostic nuclear medicine and PET scans and can be billed separately by hospitals and private imaging facilities. Type and amount of radiopharmaceuticals must be clearly documented in the technique portion of the study before the supply codes can be added.
Would you like to learn more about improving your radiology reimbursement? Contact the medical billing professionals at M-Scribe today for a free consultation.