Interventional Radiology Documentation Done Right: Best Practices for Providers

By Jennifer Bash, RHIA, CIRCC, RCCIR, CPC, RCC, CANPC
Director of Coding Education

Why does documentation matter?

Clinical documentation serves many purposes, and interventional radiology (IR) reports are no different.

First and foremost, the interventional report serves a clinical need for communication in maintaining continuity and quality of care. Historically this was really the sole purpose of documentation.

Over time, as our healthcare systems became more complex, documentation evolved to carry a lot more weight. The provider’s dictated procedure report now also serves as the legal source document. Per the American Medical Association (AMA), “provider documentation serves as evidence of the provision of services, who provided the care, the medical necessity, and the quality of care.” 

Documentation is also tied to reimbursement, as CPT and ICD-10 codes (procedure and diagnosis codes) are derived from the IR report. Auditors will rely on this report to substantiate reimbursement, or even potentially take back reimbursement if billed services are not supported in the dictation.

Lastly, the documentation supports compliance and quality measures that have expanded over the last decade through government initiatives that are tied to provider performance and potential Medicare penalties.

What is required documentation in an IR report?

While there is no “official” required documentation for IR reports, it is recommended that all reports have a clear history, title, description of the procedure, relevant findings, and final impression.

The most important thing for providers is to “tell the story.” This can be done by answering the following questions:

• Why is the patient here? What are their signs and symptoms? What is being investigated or treated?
• What is the procedure name?
• What is the access/approach for the procedure? This is important, especially in vascular procedures.
• What happened during the procedure? Describe the procedure step by step. 
• What are the relevant findings? In IR, they are utilizing imaging throughout the entire procedure. Sometimes that imaging is only to guide the procedure, but sometimes it is truly to capture images of the anatomy for diagnostic purposes.
• What was the procedure outcome? Was it successful? Were there any complications? What are the next steps for the patient?

Keep in mind, there may be other reporting elements required for hospital accreditation, quality payment programs, etc. However, following the above outline will help ensure everything is documented for accurate CPT coding for the provider.

Most Common Documentation Issues in IR

Below are some of the most common documentation risk areas in interventional radiology:

VASCULAR ULTRASOUND GUIDANCE

Many interventional procedures utilize ultrasound guidance for vascular access. Sometimes, the guidance is bundled into the primary procedure code. However, there are procedures in which it is separately billable.

This code presents a documentation burden for the provider, so it is important to review all procedure reports that utilize US guidance to ensure that all the required documentation is present.

• Required Documentation:
  • Evaluation of potential access site(s)
  • Documentation of selected vessel
  • Concurrent real-time ultrasound visualization of vascular needle entry
  • Permanent recording & reporting

MODERATE SEDATION

Moderate sedation is used for many interventional procedures and is often a billable service. However, there is a significant documentation requirement, and this is often an area of risk.

• Parameters for Coding:
  • Age of the patient
  • Was the provider administering sedation the same or different from the provider performing the procedure?
• Required Documentation:
  • Type of sedation
  • Monitoring the patient’s response to sedation by an independently trained observer
  • Minutes of intraservice* (face-to-face with patient) time spent by the provider

* Intraservice time begins with the initiation of the sedating agent and ends when the procedure is completed, the patient is stable, and the provider providing sedation feels comfortable leaving the face-to-face care of the patient

HEMODYNAMICALLY SIGNIFICANT STENOSIS

The topic of documenting “hemodynamically significant stenosis” pertains to therapeutic interventions that treat vessel stenosis (such as angioplasty and stenting) and what is deemed medically necessary to bill. Some providers use different terms to indicate the levels of “severity.” This may make clinical sense to the provider but language variations make it difficult to confidently assign a CPT code for the intervention and, ultimately, support the medical necessity and reimbursement of the procedure.

Many payer policies require that stenoses treated must be “hemodynamically significant” to be considered medically necessary to code for angioplasty or stent placement. Per CMS, in order for a stenosis to be deemed “significant,” it must be at least 50% for non-coronary lesions. There are currently several active Office of the Inspector General (OIG) and U.S. Department of Justice (DOJ) audits involving high-dollar takebacks for lack of medical necessity for these interventions.

• Documentation that would be considered “hemodynamically significant”:
  • Documentation of percentage stenosis 50% or greater
  • Severe/critical/high grade stenosis
  • Subtotal/total occlusion of vessel
• Prophylactic angioplasty is not considered medically necessary and should not be billed

DIAGNOSTIC ANGIOGRAPHY

If the patient has had a diagnostic angiogram–whether catheter-based or computed tomographic angiography (CTA)–and is referred for intervention, a diagnostic angiogram performed at the time of the intervention is not separately billable. If, however, a diagnostic angiogram is clinically indicated it may be reported separately.

• Guiding shots/roadmapping is not considered diagnostic imaging
• To bill separately for diagnostic angiography at the time of intervention, it must be clinically indicated and medically necessary and supported in the documentation
  • Change in patient status
  • Prior study had significant limitations and needs repeating

Report Formatting/Discrepancies

Discrepancies within the report can be more difficult to identify. 

Areas to monitor:

• Procedure planned does not match the procedure documented
• Catheter selections documented as specific order of selectivity, but not supported in the body of the report
• Use of “multiple” vessels selected. Must name every vessel selected/imaged
• Missing documentation of final catheter tip placement
• Documented contrast injection but no diagnostic findings

The Best Next Step…

Providers should develop a process to evaluate risk areas for their practice. Revenue cycle management (RCM) and coding staff are tremendous resources for providers to understand where documentation improvement opportunities exist. It is essential for every IR practice to have a feedback process with report reviews, regular communication, and ongoing quality monitoring and education.

In conclusion, appropriate documentation is essential for compliance and revenue maximization. Look to the experienced team at Ventra Health to guide your practice through this process. Our Provider Education team is constantly monitoring documentation for our clients, and we are at the forefront of industry news and guidance. As part of our white-glove approach to service, the Provider Education team will partner with your Client Success leader to identify documentation risk areas, monitor trends, track progress, and provide ongoing and regular education to your practice.

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References: 
AMA
CMS, NCCI Policy Manual Chapter 9
ZHealth Publishing
Society of Interventional Radiology (SIR)