what is the report called that a physician dictates to show

Follow AMA, CMS, ACR, individual payer rules, and these helpful tips for surefire billing.

By Terry Leone, CPC, CPC-P, CPC-I, CIRCC, and G. J. Verhovshek, MA, CPC
Diagnostic radiology encompasses a multifariousness of services, including diagnostic radiology (plain picture show), diagnostic ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), diagnostic nuclear medicine, positron emission tomography (PET), and mammography. The post-obit seven tips pertain to diagnostic radiology coding guidance as per American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and American Higher of Radiology (ACR) instructions, and are intended to assistance coders submit authentic claims during a time when imaging services are beingness avidly scrutinized by public and individual payers. Remember that individual payer rules take priority when billing that payer. Ask for payer requirements in writing, and be sure that billing and coding staff accept access to, and are familiar with, all payer rules.
Tip 1:
Be Certain Reports Meet Minimum Requirements
To meet ACR guidelines, all dictated radiology reports must contain:

• Heading (study name)
• Number of views or sequences (name of views – what was done)
• Clinical indication (reason for exam)
• Body of report (findings)
• Impression or determination (synopsis of findings)
• Dr. signature
• Diagnostic studies (plain films)

Tip 2:
Split up Professional and Technical Components
Most radiology procedures include both a technical component and a professional component. As a bones requirement of radiology coding, the coder must know whether to report a technical, professional, or "global" service.
The technical component (TC) of a service includes the provision of all equipment, supplies, personnel, and costs related to the performance of the exam. To report only the technical portion of a service, append modifier TC Technical component.
In that location is 1 important exception to this dominion. For services performed in a infirmary, it is assumed the infirmary is billing for the technical component of each study so hospitals are exempt from reporting modifier TC.
The professional component of a service includes the doctor work in providing a dictated study or dictated report and supervision. To study only the physician work portion of a service, append modifier 26 Professional person component. When applied, modifier 26 should exist placed in the starting time designated modifier field because information technology affects how the merits will exist paid.
A global service occurs when the dr. both bears the expense of equipment, supplies, etc., and provides supervision and/or prepares the report. Global services generally take place in an role setting, where the physician grouping owns the equipment and provides the dictated reports. When reporting global services, modifiers TC and 26 are not required.
For example, if the radiologist reads a two-view chest 10-ray in the hospital, you would report 71020 Radiologic test, chest, 2 views, frontal and lateral with modifier 26. If the radiologist supplies, in his own office, the equipment on which the X-ray is performed, written report 71020 without modifiers.
Tip 3:
Written report But the Number of Views Documented
The number of views claimed must meet the basic requirements of the CPT^® lawmaking reported. If your department or office has a list of "standard views," or the number of views to exist imaged on a patient, you cannot apply it for coding purposes. The medical report must state the number of views. It is the coder's responsibility to count the number of views and select the correct corresponding CPT^® lawmaking.
For example, a knee exam may be reported using i of iv CPT^® codes. To study 73564 Radiologic exam, articulatio genus; 4 or more than views, documentation has to substantiate four or more than views. If the doc does not country "four views," just rather documents "AP, lateral, and both obliques," that is too adequate documentation. If, nonetheless, the physician uses the phrase multiple views of the knee, the rules country y'all must report the everyman-level corresponding CPT^® code for the particular study (73560 Radiologic examination, knee joint; ane or 2 views).
This holds true for referring physician orders, likewise. If the views or the number of views are not listed in the gild, the radiology office cannot impose their department standards of, for instance, four views. Instead, the radiology department or office should contact the referring physician and ask for a new order indicating the views he would like performed.
Note, notwithstanding, that some diagnostic studies require specific view names. For instance, if the physician dictates the number of abdomen views instead of the precise names of the views, you must report the lowest-level code (74000 Radiologic exam, belly; single anteroposterior view) for that service.
Tip 4: Distinguish Sentinel View and Contrast Studies
A picket view is a single supine view of the abdomen taken prior to gastrointestinal (GI) examinations. It may be referred to as a KUB (Kidney, Ureters, and Bladder). The md must document that picture was taken, and he must dictate whatever findings from the film separately.
During a single contrast report, the patient ingests a sparse liquid barium sulfate contrast. A double contrast upper GI report uses a thicker (heavy density) barium sulfate and effervescent crystals taken with water. When mixed and swallowed, the patient's tummy fills with air or gas from the crystals. The thicker barium coats the walls of the tum and so the physician can look for ulcers, etc.
Notation: A cervical (neck) esophagram report is bundled to single and double upper GI studies; however, if there is documented medical necessity to warrant a separate exam, the esophagus report (74210-74230) may be reported with modifier 59 Distinct procedural service, in addition to the upper GI studies.
When reporting barium enema (colon) study, determine if the process used unmarried or double contrast. Unmarried contrast study uses a thin mixture of barium sulfate and h2o instilled through a tube in the patient'south rectum. When performing a double dissimilarity barium enema, the colon first is instilled with heavy density barium and air. During the 2nd contrast, air is pumped into the colon to coat the walls of the bowel with the barium. Whether a preliminary abdomen KUB is performed does not change the code prepare.
Bonus Modifier Tip: Numerous GI study lawmaking descriptors (e.yard., 74328, 74329, and 74330) specify "supervision and interpretation." These studies may be performed by a md and interpreted by a (dissimilar) radiologist, both of which may nib the service by appending modifier 52 Reduced services to the appropriate CPT^® code. The modifier tells the payer that neither billing doctor solely performed/interpreted the unabridged report.
Tip 5:
"Complete Examination" Documentation Must Be Complete
All diagnostic ultrasound examinations require permanent paradigm documentation. Abdomen and retroperitoneal studies accept additional, strict documentation requirements to code for a complete exam.
A complete abdomen study (76700 Ultrasound, abdominal, real fourth dimension with epitome documentation; consummate) requires documentation of the liver, gall bladder, mutual bile ducts, pancreas, spleen, kidneys, and the upper abdominal aorta and junior vena cava. If any one of the required anatomy is non documented, the study must be down-coded to a limited examination (76705 Ultrasound, abdominal, real fourth dimension with image documentation; limited (eg, single organ, quadrant, follow-up)).
A complete retroperitoneum written report (76770 Ultrasound, retroperitoneal (eg., renal, aorta, nodes), real time with epitome documentation; complete) consists of documentation of the kidneys, abdominal aorta, and common iliac artery origins. Alternatively, imaging of the kidneys and urinary bladder also plant a consummate retroperitoneal study when the clinical indication for the exam consists of urinary pathology.
Tip half dozen:
Oral/Rectal Administration Doesn't Count as Dissimilarity
Whether intravenous contrast was injected determines coding for CT and MRI. Only intravenous administration of contrast changes the code sets. Oral and/or rectal dissimilarity is non billable every bit a "with dissimilarity" written report. To report contrast, the technique department of the dictated report must state, "with IV or intravenous dissimilarity."
Tip vii:
Don't Forget Supplies
Diagnostic nuclear medicine studies and PET do non include radiopharmaceuticals. Hospitals and privately-owned nuclear medicine and PET departments/offices should report the radiopharmaceutical kit separately utilizing the correct supply code(south).

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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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Source: https://www.aapc.com/blog/26233-seven-tips-for-diagnostic-radiology-coding-success/

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