A thorough and accurate clinical history is essential to the radiologist interpreting an exam-both from a patient care perspective and for billing and compliance purposes. Examination protocols tailored to the patient’s needs and an accurate diagnostic interpretation cannot be accomplished without an appropriate clinical history.
Radiologists are at a particular disadvantage when it comes to obtaining patient history because they do not physically see the patient and rely on many entities to provide the necessary information about the patient, including schedulers, referring physicians, and technologists.
As such, it is extremely important that the radiologist is furnished with an appropriate clinical history. The referring physician’s order is integral to accurate interpretation and billing. Per the ACR Practice Parameter for Communication of Diagnostic Imaging Findings, the request for an imaging study should include “relevant clinical information, a working diagnostic diagnosis, and/or pertinent clinical signs and symptoms.”
Additionally, CMS states that it is the responsibility of the referring physician to provide diagnostic information for all ordered exams. As such, an order that does not contain diagnostic information does not meet regulatory requirements. Radiology groups should provide feedback to referring physicians that fail to communicate an appropriate clinical history, as ultimately the lack of this information can negatively impact patient care and billing/reimbursement.
What source documentation is acceptable when selecting an ICD-10 code?
- The radiology report
- The referring physician’s order
- Relevant information in the patient medical record*
As radiology continues to be an area of focus for payer audits, it is imperative that accurate and comprehensive diagnostic information is documented in the radiology report.
The radiology report is widely considered to be the legal source document for services rendered. Payers and auditors may not review the full patient medical record or images and often rely solely on the radiology report to substantiate the services billed. The American Medical Association (AMA) states that “Provider documentation serves as evidence of the provision of services, who provided the care, the medical necessity, and the quality of care.” The final report is also essential for patient care. Per the ACR, “the final report is considered to be the definitive means of communicating to the referring physician or other relevant HCP the results of an imaging examination or procedure.”
*Radiology groups and coders should use extreme caution when utilizing the medical record for the purposes of diagnosis selection. It would not be appropriate to search the patient records from a prior encounter to try to find a covered diagnosis, as this is subject to the False Claims Act as a fraudulent billing practice.
Per the AHA Coding Clinic, “conditions documented on previous encounters may not be clinically relevant on the current encounter.” If a diagnosis is not documented in the current record and related to the current study, it would be inappropriate to use a diagnosis from a prior encounter without supporting documentation from the provider that the patient the still experiencing the sign/symptom/condition.
Ventra Best Practices
It is Ventra’s position that the most efficient and effective way to ensure accurate and compliant billing is to rely on the radiology report to substantiate all of the necessary information required for coding.
In accordance with the ACR’s Practice Parameter for Communication of Diagnostic Imaging, the dictated radiology report should contain the following:
- Relevant Clinical History
- Technique/Description of the Study
- Findings
- Final Impression
The Benefits:
- Efficient and timely coding and billing
- Reduced risk of coding errors
- Reduced medical necessity denials
- Reduced compliance risk
Resources:
Centers for Medicare and Medicaid System (CMS)
The American Medical Association (AMA)
ACR Practice Parameter for Communication of Diagnostic Imaging
AHA Coding Clinic Third Quarter 2013
