Deborah K. Mann & Jennifer Bash. Coding Documentation and Education Managers

Transcription

1 Deborah K. Mann & Jennifer Bash Coding Documentation and Education Managers

2 OBJECTIVES Review the basics of Diagnostic, CT, & MRI documentation Risk areas in radiology associated with Diagnostic, CT, & MRI: Views CTA 3D Reconstruction Common questions in diagnostic, CT, & MRI

3 Sources American Medical Association American College of Radiology American Hospital Association

4 Disclaimer The information presented is based on the experience and interpretation of the presenters. Though all of the information has been carefully researched and checked for accuracy and completeness, ADVOCATE does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation.

5 Paid Resources CPT/ICD-10 Books AMA CPT Assistant Radiology Coding Examples Coding Strategies MedLearn (Panacea) Zhealth

6 Free Resources CMS LCD/NCD The ACR Radiology Coding Source Online Medical Dictionary Online Anatomy Google

7 Components of the Radiology Report CLINICAL INDICATION/REASON FOR EXAM: Signs, symptoms, and any pertinent medical history REPORT HEADER: Should include the body site, type of modality, exam performed, and any following modality specific information REPORT BODY: Technique, including any contrast administration, medications and/or radiopharmaceuticals, catheters, and devices Any patient complications or reactions Diagnostic findings Any comparison studies IMPRESSION: Final conclusion/diagnoses and any recommended follow-up

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9 Diagnostic X-ray Document: Anatomical site Number of views Type of views

10 Scoliosis Studies 4 new codes Simplifies scoliosis studies All based on number of views (1-6 views) Similar coding structure as other spine codes

11 Common Questions If 2 images of the whole spine are obtained but they are both AP views how is this coded? Do physicians need to document type views?

12 Hip Studies 6 new codes Unilateral vs. bilateral codes Pelvis included when performed Based on number of views

13 Hip Studies Hip, unilateral 1 vw vws vws Hip, bilateral: 2 vws vws vws All exams include pelvis when performed

14 Hip Studies Single view unilateral hip and single view of the pelvis (2 vws) Single view of bilateral hip (2 vws) Single view bilateral hip with image of pelvis (3 vws)

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16 CTA CTA requires completion and documentation supporting 3D Reconstruction The following support 3-D documentation: Maximum Intensity Pixel (MIP) Maximum Intensity Projection (MIP) Volume Rendered Images Surface Shaded Rendering 3D Reconstructed Images 3D not supported bill as CT

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18 CTA-Sample Report Indications: Right-sided numbness and weakness for several days. Acute stroke noted in the left brainstem on MRI dated 4/15/2016 TECHNIQUE: CT angiography of the circle of Willis: was performed using 100 cc of Omnipaque 350 intravenously FINDINGS: Contrast-enhanced CT of the brain shows chronic bilateral maxillary sinus inflammatory disease. There is no abnormal enhancement. The intracranial internal carotid arteries show severe stenoses bilaterally with atherosclerotic calcifications. The anterior cerebral arteries appear normal bilaterally. The middle cerebral arteries appear normal bilaterally. Posterior cerebral arteries are patent bilaterally right vertebral artery is developmentally small. Left vertebral artery is normal. Basilar artery is normal. No sign of cerebral aneurysm. Bilateral chronic maxillary sinusitis noted. No abnormal enhancement in the brain. IMPRESSION: 1. Severe stenoses of the intracranial internal carotid arteries bilaterally 2. No sign of aneurysm. THIS REPORT IS LACKING DOCUMENTATION OF 3D TECHNIQUE REQUIRED FOR CTA.

19 3D Reconstruction 76376: 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; not requiring image post-processing on an independent workstation 76377: 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; requiring image post-processing on an independent workstation

20 Documentation Requirements: 3D Reconstructed Imaging (technique must be supported) 3D Reconstruction Independent workstation or not Concurrent supervision (added 2013)

21 Concurrent Supervision Defined as: active participation in and monitoring of the reconstruction process that includes: design of the anatomic region that is to be reconstructed; determination of the tissue types and actual structures to be displayed (e.g., bone, organs, and vessels); determination of the images or cine loops that are to be archived; and monitoring and adjustment of the 3D work product.

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23 New Code: Lung Cancer Screening G0296 Counseling visit to discuss need for lung screening G0297 Low-dose CT scan (LDCT) for lung cancer screening To be used effective 1/4/16 Pt should have documented history of smoking or be a current smoker Retroactive Payment NCD effective date 2/5/15 ICD-9 code for 2/4/15-9/30/15 DOS must be V15.82 (Hx of smoking)

24 Lung Cancer Screening UPDATE : Implementation date July 5, 2016 F Nicotine dependence, cigarettes, uncomplicated F Nicotine dependence, cigarettes, in remission F Nicotine dependence, cigarettes, with withdrawal F Nicotine dependence, cigarettes, with other nicotine-induced disorders F Nicotine dependence, cigarettes, with unspecified nicotineinduced disorders Effective DOS Oct 1,2015

25 Q&A MRI Brain and IAC Q: What is the most appropriate way to code an MRI of the brain and internal auditory canal (IAC)? A: If a full and complete diagnostic study is performed of both the brain and the IAC on the same day, it is appropriate to code twice. If only a few extra sequences are performed with focus on the IAC, this is considered part of the brain exam and should not be coded separately. Coding for both should be a RARE occurrence, not a protocol Documentation is key: Both should be ordered Should support medical necessity for both exams Recommend a separate paragraph and findings in the report

26 Q&A MRCP Q: How should a magnetic resonance cholangiopancreatography (MRCP) be reported? A: MRI of the abdomen ( ) + 3D reconstruction. If 3D reconstruction is performed and appropriately documented under concurrent supervision.

27 Radiology Risk Areas Inadequate documentation Inadequate communication Missed reimbursement

28 The Radiology Report Legal Source Document If it s not documented it didn t happen Physician doesn t document it s not billable Code based on dictated portion of the report

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30 Thank you!

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