In radiology, like all other medical specialties, proper documentation is critical to achieving appropriate reimbursement. If the proper terminology is no used or important descriptors are omitted from the radiology report, the physician may not get paid for the services he or she performed.

HAP has been helping physicians achieve optimal reimbursement for years, and we have compiled this list of guidelines for radiologists to consider when dictating reports. The guidelines are broken up into two sections: Study- Specific and Diagnostic.      

Study-Specific Guidelines

Complete Ultrasound of the Abdomen

The report must include the areas listed below.  Documenting non-visualization of an organ or vessel is acceptable (e.g. surgically absent gallbladder).

• Liver, gall bladder and common bile duct
• Pancreas
• Spleen
• Kidneys
• Upper abdominal aorta and inferior vena cava

Complete Ultrasound of the Retroperitoneum

The report must mention:

• Kidneys
• Abdominal aorta and common iliac artery origins
• Inferior vena cava

OR

• Kidneys, ureters and bladder if performed for urinary indications

Documenting Fluoroscopic Guidance

For fluoroscopic guidance, mention the fluoroscopy time and number of spot films which were taken and read. 

Ultrasound Guidance for PICC

The report must state that “permanent images were recorded.”

X-Ray Documentation

• The number of views should always be documented in the report.
• Types of views can affect procedure code selection, especially for chest, abdomen, knee and spine x-rays.
• For spine x-rays, be sure to mention flexion, extension, bending or oblique views when performed.

CT Angiography and 3D

When dictating a CTA report, documentation of 3D reconstructions must be included.  The reconstruction does not have to be done on a separate workstation. 

Venous Duplex/Doppler

• Be sure to specifically mention all major veins that were imaged.
• Three elements must be documented in each study: imaging, spectral analysis and color flow.

Breast Ultrasound

• Ultrasounds are split into “limited” and “complete.”
• “Complete” requires documentation of all four quadrants and retroareolar area.
• Any report that doesn’t mention all five areas is classified as “limited” and reimbursed at a lower rate.

Breast Tomosynthesis

Must use the word “tomosynthesis” in the dictation; 3D is not acceptable (e.g. “tomosynthesis was performed”).

Conscious Sedation

Must mention the sedation time and indicate that the physician directly supervised the administration of the sedative (e.g. “Under my direct supervision…”).

Diagnostic Guidelines 

Conditions cannot be coded unless they are proven to exist.

Information on a potential condition (e.g. fracture, DVT) that a study is looking for is not helpful from a billing perspective.  We cannot code conditions listed as:

• “Rule out”
• “Possible”
• “Probable”
• “Suspected”

Personal or family history of a condition can be coded, but these diagnoses are not payable for many studies.

Provide as many applicable indications for the study as possible.

If the findings of the study are normal, a diagnosis is still needed to bill. There must have been a sign or symptom that led to the study being ordered such as:

• Pain in the body area
• Injury to the body area
• Swelling in the body area
• Shortness of breath
• Fever
• Cough
• Dizziness/vertigo
• Syncope/fainting
• Nausea
• Vomiting
• Diarrhea
• Related chronic condition (e.g. diabetes, renal disease, asthma)
• And many more

Be as specific as possible with diagnoses.

When a study is being done because of pain, trauma or swelling, be sure to clearly state the location. 

• We cannot assume that a general diagnosis such as “pain” or “injury” applies to the area of the study.
• If the patient has studies performed on multiple body areas, please be sure the appropriate specific diagnosis appears in each report (e.g. an ankle x-ray shouldn’t list elbow pain as the only indication)

Conclusion

This is by no means an exhaustive list of issues and errors, just some of the most common ones we’ve seen in radiology reports. Use this information as a guideline for the proper documentation of radiology procedures to achieve maximum reimbursement. Subscribe to our blog now for more on this topic and expert advice on a variety of radiology practice revenue cycle management issues.

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Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners. 

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