Get Paid for What You Do: Dictation Patterns and Impact on Billing Accuracy

Article Outline

• Abstract
• Introduction
• Want to invest?
  • Cosmic Grocers
  • Cars for All
  • Finished Furniture
• Dictated reports and procedure coding
• Coding parameters
• Enough theory, now some reality
  • Problem 1: Number of Views
  • Problem 2: Use of Contrast
  • Problem 3: Imaging Guidance
  • Problem 4: Complete versus Limited Examinations, CPT-4 Instructions
  • Problem 5: Use of Code Modifiers
• Fraud and compliance
• Radiology coding is a science
• Summary
• References
• Copyright

No one would knowingly invest in a business whose principal executives knew little or nothing about the key components determining reimbursement for the services provided. Superimpose on that lack of knowledge a regulatory environment in that business sector that places owners and key employees at risk for accusations of fraud and abuse as well as in jeopardy of large fines and potential exclusion from the marketplace for the largest consumer of a company’s product if billing is done incorrectly. Yet this is exactly the case in many radiology practices today. A significant number of radiologists who provide excellent quality medical care produce dictated reports that demonstrate complete ignorance of the parameters used by their billing personnel to generate accurately coded claims, thus losing significant legitimate clinical practice revenues while placing themselves and their practices in jeopardy. This article does not outline ways to game the system or inappropriately augment practice revenues. Rather, it describes many of the basic elements needed in the dictated reports produced by radiologists in their daily work, calculates examples of the financial impact of medically correct but poorly documented reports, and provides dictation guidelines for radiology residents and radiologists in practice that, if adopted, should ensure that you get paid properly for what you do.

Key Words:  Coding , dictation , economics

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Introduction 

Billing for radiologic services is performed using standardized code sets. Most commonly, this is accomplished using a code or set of codes identifying the medical care that has been delivered (Current Procedural Terminology, Fourth Edition [CPT-4]) [1] as well as one or more codes describing the clinical indication that necessitated the procedure (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) [2]. In the vast majority of settings, billing personnel employed by the practice or a contracted billing service must convert descriptions of procedures performed and the clinical information provided into properly filed claims for payment.

Radiology residents undergo extensive training to prepare them to diagnose and treat a vast array of illnesses and restore or preserve patients’ health. Unfortunately, very few of them are equipped with the knowledge necessary to preserve and promote the financial health of the practices or academic departments they join at the conclusion of this training. This is not to say that they cannot accurately interpret diagnostic examinations or competently perform the minimally invasive procedures that encompass the full scope of radiologic practice. Rather, it only recognizes that they must also learn during their training the importance of reporting those services in a manner that allows conversion of that health care delivery into practice or department revenues.

Radiologists, whether in private practice or academic departments, most frequently maintain the dictating and reporting patterns that they developed during their residencies and fellowships. Although old habits die hard, when practice or department profitability depends on it, new habits need to be developed on the basis of several fundamental tenets that allow billing personnel to accurately code the services delivered, ensuring proper payment.

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Want to invest? 

Before proceeding with these radiology-specific guidelines, let us consider a few business situations that parallel the situation of a radiologist who does not dictate properly. Imagine that you are visiting these companies and observing the operations, considering whether you want to become a partner.

Cosmic Grocers 

Cashiers at Cosmic Grocers have an unusual pattern at the checkout counter. For each transaction, although they enter the food type into the cash register, they fail to record the amount or size of the package purchased. Receipts simply read “eggs, milk, oranges, cereal,” and so on. For each item, the register defaults to the smallest size or lowest number available. The auditor is having trouble reviewing the books.

Cars for All 

The inventory at Cars for All includes a wide range of makes and models of automobiles, and these are all properly labeled. The manager is having a difficult time negotiating prices, however, because the window stickers fail to identify which options are installed in which cars. A particular model may come with or without air conditioning, for example, but the manager cannot charge for this option, because he does not know how each individual car is equipped. Profits have been dropping.

Finished Furniture 

Finished Furniture is renowned for the high-quality finishes on their wood furniture. They offer multiple different types of veneer wood and stain combinations, each requiring a different amount of work and materials. Unfortunately, their craftspeople get confused with the multiple possible permutations and combinations. They have resisted standardized reporting methods, and each has developed his or her own “system.” Even though they are asked to record the materials used and individual steps performed, there continues to be inconsistency, making it extremely difficult on the sales personnel, who must repeatedly call and ask for clarification. In addition, the errant craftspeople are content with their paychecks each month and never see the negative impact of their inadequate reporting. They are paid just as well as those craftspeople who report correctly. Is this furniture company finished?

It is safe to say that we would all decline the “opportunity” to become an owner in Cosmic Grocers, Cars for All, or Finished Furniture. Although they may all deliver high-quality products, these are clearly poorly run businesses with significant deficiencies in information transfer and correct billing that negatively affect their chances of long term financial success and viability. If we can recognize it in these examples, why then do many radiologists continue to tolerate similar techniques in their own practices?

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Dictated reports and procedure coding 

The vast majority of radiologic service is delivered in response to requests from other health care professionals. These requests usually specify procedures and hopefully describes the patients’ conditions or clinical questions prompting the examinations. Requests may or may not be written exactly in concert with the ICD-9-CM and CPT-4 coding language. Clinical histories must be related to the examinations performed. In addition, radiologists are expected to follow protocol during examinations (e.g., the number of radiographic views, the use or nonuse of contrast agents, the level of selective catheterization required, optimal imaging guidance). As a result, disease (ICD-9-CM) and procedure (CPT-4) coding for subsequent billing is best performed from a dictated report that documents a patient’s history, which justifies clinical necessity and accurately and completely describes what was actually done. Obviously, the medical accuracy of a report is most important from the perspective of patient care delivery. From the billing and business perspectives, it is critical that a report include all the necessary information:

In 2003, the American Medical Association’s [1, p. xiii] CPT Editorial Panel revised the introductory language to state,

“Select the name of the procedure of service that accurately [italics added] identifies the service performed. Do not select a CPT code that merely approximates the service provided.”

In short, close is not good enough.

Additionally, the CPT-4 instructions and introductory language often give very specific requirements for certain codes or families of codes. These must be understood, and sufficient information must be included in a dictated report to allow office personnel to follow those instructions and choose the proper codes.

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Coding parameters 

Several general as well as modality-specific principles must be followed if coders are to choose “accurate” procedure codes and practices are to be properly reimbursed. Although a complete discussion of all of these parameters cannot be covered in a single article, some of the more critical and exemplary are as follows:

And it is not enough to be familiar with the codes and rules at one point in time. As pointed out in examples below, if a radiology practice intends to continue to be reimbursed properly, there must be a diligent effort to stay abreast of the annual changes in the codes and rules of application.

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Enough theory, now some reality 

A few specific examples will likely make the point and hopefully convince a few skeptics that this is in fact important. In each of these, a sample dictation is analyzed. Each sample report conveys the necessary clinical information, thus satisfying the first major purpose of that report, but as the reader will see, though the patient may do well, the practice may suffer. In each case, it is assumed that sufficient clinical history was obtained to meet the requirement of medical necessity. The relative value unit (RVU) values quoted are from the Proposed Rule for the 2005 Medicare Physician Fee Schedule [3], and the dollar values were calculated using the anticipated 2005 Medicare conversion factor. The impacts could be greater depending on the payer and reimbursement fee schedule.

Problem 1: Number of Views 

Procedure requested: Lumbar spine.

Report: Lumbar spine, 4/6/03.

The vertebral bodies are normal height and anatomically aligned. No fracture or disc space narrowing. The visualized sacrum appears normal.

Impression: Normal lumbar spine.

Clearly, the clinical need has been met, but when this report reaches the coders, they may develop low back pain. What CPT-4 codes will “accurately” reflect the service rendered?

There are two CPT-4 codes for radiographic lumbar spine examinations: 72100, radiologic examination, spine, lumbosacral; two or three views (global reimbursement of 1.02 RVUs); and 72110, radiologic examination, spine, lumbosacral; minimum of four views (global reimbursement of 1.40 RVUs). In addition, there is a code (72020) for a single view of the spine that could be correct.

The reimbursement difference between the two lumbar spine codes is approximately 38%. If a practice does 1000 lumbar spine examinations per year, using the 2005 Medicare Physician Fee Schedule conversion factor, the difference is about $14,400. If, however, the radiologists don’t indicate the number of views on all spine and extremity examinations, and the practice does a total of 50,000 of these per year, the result could be hundreds of thousands of dollars of lost revenues.

Problem 2: Use of Contrast 

Procedure requested: lumbar spine CT following myelography.

Report: CT lumbar spine, 6/1/04.

Axial sections obtained L2 through S1. Comparison is made with earlier myelography. The bony structures are normal. The discs at L2–3, L3–4 and L4–5 appear normal. At L5–S1, there is a left lateral disc protrusion displacing and obscuring the forming S1 nerve root.

Impression: left L5 to S1 disc protrusion with mass effect on left S1 root.

Again, the clinical information has been transmitted, and the spine surgeon knows how to proceed to treat the patient’s radiculopathy. The coder, unfortunately, still has a deficit.

There are three CPT-4 codes for CT examinations of the lumbar spine:

Because the report makes no mention of contrast material at all, the coder must either contact the radiologist or have a prior understanding that the statement “comparison is made with earlier myelography” made in the report implies that there is contrast within the thecal sac. In the CPT-4 radiology section, there are very clear instructions regarding the administration of contrast materials, which state that “the phrase ‘with contrast’ used in the codes for procedures performed using contrast for imaging enhancement represents contrast material administered intravascularly, intra-articularly or intrathecally” [1, pp. 274–5]. There are also instructions on when additional codes can and cannot be used for the injection of contrast material. The instructions go on to state, “Oral and/or rectal contrast administration alone does not qualify as a study ‘with contrast’” [1, pp. 274–5]. The difference between the correct code (76132, with contrast) and the incorrect code (76131, without contrast) is 17%, a significant impact.

Problem 3: Imaging Guidance 

Procedure requested: Liver biopsy.

Report: Percutaneous biopsy of liver, 10/9/03.

Under usual aseptic conditions, and using 1% local lidocaine anesthesia, 18-gauge core biopsies were obtained from the right lobe of the liver via the midaxillary line. The core samples were placed in formalin and sent to the laboratory. No immediate complications.

Impression: Technically successful percutaneous core biopsy of liver.

The referring gastroenterologist has been fully informed that the biopsy was obtained and that a histologic result would be forthcoming. The coder’s work, however, may be jaundiced. There is no mention in the report of any imaging guidance modality (e.g., ultrasound, CT), and thus, the coder cannot submit any code other than that for the percutaneous liver biopsy. Missing codes might include:

To submit these imaging guidance codes, not only must the use of guidance be documented in the report, but some permanent recorded image must be produced (film, photo printer, electronic) illustrating that guidance.

Regardless of the modality used, significant reimbursement is left unclaimed. Depending on the method used, this results in a loss of between $145 and $328 per procedure. The same concept applies regardless of the imaging-guided procedure performed, unless the imaging guidance is specifically included in the procedure code descriptor.

Problem 4: Complete versus Limited Examinations, CPT-4 Instructions 

Procedure requested: Obstetric ultrasound.

Report: Obstetric ultrasound, 9/21/03.

Patient examined using real-time scanning. A single fetus is identified in cephalic position. Fetal and cardiac motion present. Amniotic fluid volume is normal. Placenta is posterior and appears normal. Multiple measurements obtained indicating a gestational age estimate of 24 ± 2 weeks. No fetal anomalies seen.

Impression: Single viable fetus with best gestational age estimate 24 weeks.

The obstetrician likely has all the information needed, but there will be a definite problem with code delivery. The obstetric ultrasound codes were revised in 2003 with extensive introductory language that defines what were previously generically listed as complete and limited obstetric ultrasound examinations. The introductory language lists specific fetal and maternal anatomy (“survey of intracranial/spinal/abdominal anatomy, 4 chambered heart, umbilical cord insertion site, placenta location and amniotic fluid assessment and, when visible, examination of maternal adnexa” [1, pp. 291–2]) that must be examined to warrant use of the complete code:

That CPT-4 introductory language also states, “Report should document the results of the evaluation of each element described above or the reason for non-visualization” [1, p. 292]. Unfortunately, this report fails to document those elements, and thus, the coder cannot justify the use of this code (valued at 3.59 RVUs) and must resort to the lesser code:

This is a 33% reduction, even though the necessary imaging work sufficient for code 76805 was probably performed.

It is critical to note that similar introductory language defining complete and limited ultrasound examinations exists in the CPT-4 [1, p. 290], with specific requirements for abdominal or retroperitoneal [1, p. 291] and nonobstetric pelvic [1, p. 293] examinations as well as echocardiography [1, pp. 362–3]. These requirements may best be met with “bullet list” reporting forms that remind image-acquiring sonologists and dictating radiologists of those required elements.

Problem 5: Use of Code Modifiers 

Procedure requested: portable chest x-ray.

Report: portable chest x-ray, 7/21/04.

Anteroposterior chest film compared with prior examinations. A new left central venous pressure line is in place with the tip in the superior vena cava. No pneumothorax. Lungs clear. Heart size normal. No congestive heart failure.

Impression: central venous pressure catheter in good position without pneumothorax.

The intensivist is happy, because his or her new central venous pressure catheter is well placed, and there are no evident problems. The radiology practice may have a complication, however, and be denied payment for this examination if the patient had already had a portable chest x-ray earlier on the same day. There is nothing in the report (e.g., time of the current examination, mention that the earlier comparison examination was on the same day) to alert the coder that the -59 modifier, which “indicates that a procedure or service was distinct or independent from other services performed on the same day” [1, p. 402], should be applied to that claim submission. The CPT-4 has a number of modifiers that are important to radiologists, and knowledge of these with appropriate documentation in procedure reports enabling their use is critical to avoid inappropriate payment denial.

Numerous additional examples could be cited. The common theme is that radiology reports need to completely describe the services delivered for accurate coding and billing as well as satisfy the primary objective of clinical communication.

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Fraud and compliance 

We practice today in a highly scrutinized and regulated environment. The US Department of Justice has a legion of investigators dedicated to stamp out abuse of the Medicare Trust Fund. One response to the “coding-deficient” reports described above might be that coders should make certain assumptions on the basis of their understanding of clinical radiology practice or past experience. That may work in a number of instances to preserve some of the potential lost revenues but would be a potentially practice-threatening mistake. If a practice is ever audited for regulatory compliance, the radiology reports will be the determining factor of what procedures were done, whether there was sufficient documentation of clinical necessity, and whether the billing practices were correct. Most investigators are not likely to accept the contention “We really did that work though it was not documented in the report.” Accept the fact that in the eyes of auditors, if it isn’t documented, it didn’t happen!

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Radiology coding is a science 

Accurate coding and ensuring appropriate reimbursement are team efforts. Clearly, a radiology report serves as the core document. As described, it must contain the critical information that justifies the submitted claim. For long-term viability and success, each practice must recognize the need to educate radiologists and maintain a current coding knowledge base. The ACR provides for its members, and through subscription to nonmembers, several authoritative coding publications to assist in this continuing educational process. Radiology coding certification is now available through the Radiology Coding Certification Board (http://www.rccb.org), a national nonprofit organization specializing in radiology coding examination. Practices that contract their billing functions need to be attentive to the coding conventions practiced by the billing organizations. In the end, however, radiologists are ultimately responsible for the documentation and claims submitted.

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Summary 

With continued downward pressure on the per-procedure reimbursement for radiologic procedures, it is critical for practice financial viability that all radiologists and practices do everything they can to ensure that they are reimbursed for all the services that they provide. To do this, radiologists must educate themselves on the importance of the content and format of their reports relative to accurate procedure coding and payment. Although a complete discussion of all CPT-4 coding rules is beyond the scope of a single article, the basic tenets of radiology reporting and coding described above illustrate the need for radiologists to prioritize this knowledge and incorporate any necessary changes into their dictation patterns to be sure that they are doing as much for the health of their practice as that of their patients. If we are smart enough not to invest in Cosmic Grocers, Cars for All, or Finished Furniture, all companies with clearly inadequate business and billing practices, we must also be smart enough to recognize that our practices will only be good investments if we accept our responsibility to document our services sufficiently to get paid for what we do.

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References 

1. Current procedural terminology 2005 . Chicago: American Medical Association Press; 2004;
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2. International classification of diseases, 9th revision, clinical modification . Los Angeles: World Health Organization; 2004;
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3. 42 CFR . Fed Reg . 2004;69(150):
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