Radiology Coding Guidelines and Best Practices

Updated Radiology Coding Guidelines For 2021

UPDATE: Beginning April 1, 2021, United Healthcare (UHC) is changing the prior authorization requirements for some outpatient services, including imaging-guided radiation therapy. Now, beyond intensity-modulated radiation therapy and proton beam therapy, these additional services will require prior authorization or risk non-payment from UHC:

  • Fractionation for breast, prostate, lung, and bone metastasis cancers

  • Stereotactic body radiation therapy and stereotactic radiosurgery

  • Image-guided radiation therapy

  • Special and associated radiation therapy services – selective internal radiation therapy, Yttrium 90 and implantable beta-emitting microspheres for treatment of malignant tumors

Seeking reimbursement for radiology services can be complicated with both private and public payers critically scrutinizing both diagnostic and interventional imaging services. Often, individual payers have their own specific rules that take priority, further complicating an already challenging claims process.

The American Medical Association’s (AMA) CPT code manual is revised annually to reflect new and updated technologies, changes related to bundling mandates, and guideline revisions.

This year has proven to be extraordinary with the coronavirus pandemic and continuing upheaval in the healthcare system as well as the rest of the economy. One such change was the 3.75% increase in Medicare Physician Fee Schedule (MPFS) payments for calendar year 2021 from the Centers for Medicare and Medicaid Services (CMS) along with a suspension of the 2% payment adjustment or sequestration until at least March 31, 2021. Additionally, there was a delay in implementing the add-on code, G2211, for evaluation and management until 2024.

Comprehensive Coding for Radiological Services

Radiology is a medical specialty that uses techniques such as X-ray, Computed Tomography (CT), CT Angiography (CTA), Magnetic Resonance Imaging (MRI), MR Angiography (MRA), Ultrasound, Nuclear Medicine, and Positron Emission Tomography (PET) scans to diagnose as well as treat diseases or health conditions.

In this blog, we examine the difficulties in radiology coding and provide radiology billing and coding solutions to help you keep abreast of changes in the field.

Creating a Complete Radiology Report

The golden rule of medical coding is that “if something is not documented then it was not done”. Therefore, the ACR practice guidelines state that a complete radiology report is mandatory to support proper code assignment and optimal reimbursement. The following elements, at the very least, are required in the radiology report:

  • Patient name

  • Referring physician name

  • Date, time, and location of study

  • Patient history

  • Reason for the study

  • Date and time of dictation and transcription

  • Radiologist’s signature

According to the ACR practice guideline, the radiology report “should address or answer any specific clinical questions. If there are factors that prevent answering of the clinical question, this should be stated explicitly”.

Radiology Billing and Coding Solutions

The intricacies and nuances of coding can make or break the success of your revenue capture. Using correct coding practices has the power to reduce denials and exponentially increase successful claims. Accurate coding means accurate charges for every patient’s treatment, consultation, and medication.

On the other hand, sluggish, inaccurate coding can back up revenue in a traffic jam of denials that often never get resolved. Key patient access and RCM areas for focus include:

  • Thorough insurance verification and pre-collections on amounts estimated to be due from the patient

  • Timely documentation completion for all providers to expedite the RCM process

  • Using proper CPT coding and documentation following a patient encounter and staying abreast of changes to guidelines and bundling requirements

  • Prior authorization with the ability to address same-day and emergent patient needs through the Authorization Determination Agent, a feature of the Infinx Prior Authorization Software, prior authorizations are identified and determined in real-time, saving valuable time when scheduling important procedures

  • Precise ICD-10 coding and billing procedures

  • Timely follow up and denial management

  • Insurance discovery to identify undisclosed patient coverage through insurance clearinghouses

CPT Coding Changes for 2021

Diagnostic Radiology

Screening CT of the Thorax

  • Codes 71250, 71260, 71270 are diagnostic. Also, a new CT of the thorax code will be available for reporting low-dose lung cancer screening

  • The current HCPCS code G0297 was identified by the Centers for Medicare and Medicaid Services (CMS) as a high-value growth screen. It was subsequently referred to the editorial panel to establish a Category I CPT code to report low-dose CT for lung cancer screening

Fluoroscopic Guidance

  • Codes 64400-64450 and 64455 (Introduction/Injection of Anesthetic Agent and/or Steroid into the Somatic Nervous System) will be added in the inclusionary parenthetical notes following Codes 77002 and 77003 – Fluoroscopic Guidance

Ultrasound Follow-up Study

  • Code 76970 – Other Diagnostic Ultrasound Procedure has been referred to the CPT Editorial Panel for deletion due to low volume

Urography

  • Code 74425 – Diagnostic Radiology Procedures of the Urinary Tract will be revised, and a reciprocal parenthetical will be added clarifying that it can be reported with codes 50390, 50396, 50684, and 50690

Interventional Radiology

Percutaneous Core Needle Lung Biopsy

  • Code 32405 – Under Excision/Resection Procedures of the Lungs and Pleura will be deleted and replaced with a new code that bundles percutaneous core needle lung biopsy with imaging guidance when performed

Specifically, Codes 32405 and 77012 were identified by the editorial panel as code pairs being performed together 75% or more of the time, and it was recommended that they are bundled.

Medical Physics

Medical Physics Dose Evaluation

There will be a new Category I code in Radiology, Diagnostic Radiology (Diagnostic Imaging), Other Procedures subsection of the CPT to report the assessment and calculation of radiation dose, and the potential adverse iatrogenic effects received by the patient that may require follow-up observation or treatment.

This will be a technical component only code since a medical physicist most often performs this actual service.

Evaluation and Management

Evaluation and Management (E/M) Visits
With the first major overhaul to E/M reporting in 25 years, the editorial panel has approved significant revisions to the E/M code descriptors.

According to the AMA, “history and/or physical examination as a component for code selection will be eliminated; code level selection will be based on medical decision making (MDM) or time.

There will also be changes in the definition of MDM and time when used with these codes. The E/M guidelines will be revised extensively to reflect these changes.”

These changes include:

  • Eliminating history and physical exam for code selection and reducing the administrative burden

  • Allowing physicians to choose between medical decision-making (MDM) or total time to determine E/M

  • Modifying MDM criteria to affect the management of a patient’s condition

Following the lead of the CMS’ overall initiative to reduce unnecessary documentation, these changes will:

  • Ensure payment levels for outpatient E/M visit codes are resource-based,

  • Minimize the need for audits, and

  • More accurately reflect the services provided

As part of the new E/M code structure, there will be a new add-on code created to report additional provider time in 15-minute increments. This new add-on code will be reported with codes 99205 and 99215. Other changes include:

  • New patient code 99201 will be deleted

  • New patient codes 99202, 99203, 99204, and 99205, and established patient codes 99211, 99212, 99213, 99214, and 99215 codes will be editorially revised

  • Prolonged services codes 99354, 99355, and 99356 will also be revised to reflect these changes

Last Consideration — Clinical Decision Support Mechanism

From the radiology perspective, the Appropriate Use Criteria (AUC) program and the Clinical Decision Support Mechanism (CDSM) were conceived as a process that would complement and elevate the referring provider’s diagnostic practice, strengthen the Medicare patient experience, and reduce needless advanced image testing. The requirement impacts all physicians, APP, and facilities billing Part B Services to Medicare.

With the education phase extended through 2021, CMS has an approved list of vendors, of which Infinx is a participating member, that can provide the advanced automation to process certificates of compliance for CDSM. Active participation will ensure payment from Medicare after the mandatory implementation date of January 1, 2022.

The following HCPCS Level II modifiers have been established for the AUC/CDSM program and should be added to all claims.

  • MA – Ordering professional is not required to consult a clinical decision support mechanism due to service being rendered to a patient with a suspected or confirmed emergency medical condition

  • MB – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of insufficient internet access

  • MC – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues

  • MD – Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of extreme and uncontrollable circumstances

  • ME – The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

  • MF – The order for this service does not adhere to the appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional

  • MG – The order for this service does not have appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional

  • MH – Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider

  • QQ – Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional

To Sum Up

You can prevent costly mistakes by knowing all coding updates as well as the specific challenges faced in your practice or hospital. Having a complete radiology report can help ensure you and your team are using the right codes. Coding precision and accuracy results in maximum revenue for any healthcare organization.

Radiology is ground zero in the efforts to reduce health care usage. Whether utilizing an internal billing and coding department or engaging a third-party partner, a proactive approach to the healthcare payment lifecycle sets the stage for successful revenue cycle management.

Contact us today to put our radiology billing and coding solutions to work for you.

To Sum Up

You can prevent costly mistakes by knowing all coding updates as well as the specific challenges faced in your practice or hospital. Having a complete radiology report can help ensure you and your team are using the right codes. Coding precision and accuracy results in maximum revenue for any healthcare organization.

Radiology is ground zero in the efforts to reduce health care usage. Whether utilizing an internal billing and coding department or engaging a third-party partner, a proactive approach to the healthcare payment lifecycle sets the stage for successful revenue cycle management.

Contact us today to put our radiology billing and coding solutions to work for you.

About the Author

Infinx Healthcare provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

Leave A Comment

Speed Up Prior Authorizations Using Automation and Artificial Intelligence

Accelerate your approvals, collect more revenue, and improve the patient experience

Schedule a Demo