radiology report review with patient cpt

As noted in the American Medical Association’s Principles of CPT Coding, if a patient comes to an office for a new or established visit and brings the physician his or her medical records, including X-rays, the review or reread of the X-rays would be considered part of the face-to-face evaluation and management (E&M) service provided to the patient and would not be reported separately.

Full Answer

What is the CPT code for radiology in a hospital?

In the hospital (facility) setting, usually a radiology group is contracted to read the image and produce a written report, adding modifier 26 to the CPT code for the service while the facility, who owns the larger equipment (eg, MRI, CT) that produces the image will report the code for the service with modifier TC.

Do outpatient radiology procedures cause coding quality concerns?

Outpatient diagnostic radiology procedures can cause coding quality concerns because they are hard-coded (obtained from the chargemaster) by radiology department staff who usually do not have formal coding training.

What is the CPT code for IMRT in radiology?

IMRT plan (CPT code 77301) includes therapeutic radiology simulation-aided field settings. Simulation-aided field settings for IMRT shall not be reported separately using CPT codes 77280-77290.

How can ICD-9-CM and CPT improve radiology coding workflow?

A well-designed ICD-9-CM and CPT radiology coding workflow will prevent errors prior to reporting data and reduce the need for claim denial follow-up. The most effective solution for bridging the radiology charge capture, coding workflow, and communication gap is to employ credentialed coding professionals within the radiology department.

Is there a CPT code for reviewing medical records?

o CPT 99358- Review of medical records in excess of the 30 minutes included in 99455/56. For the first hour of record review thereafter, CPT code 99358 shall be used. The medical provider must itemize the total time spent reviewing the medical records.

What does CPT code 99241 mean?

CPT® Code 99241 - New or Established Patient Office or Other Outpatient Consultation Services - Codify by AAPC. CPT. Evaluation and Management Services. Consultation Services. Office or Other Outpatient Consultation Services.

Can CPT 71046 and 71100 be billed together?

There are no edits on 71046 with 71100, only 71045, 1 view chest with 71100.

What is the CPT code 76377?

CPT code 76377 is reported when the 3D post-processing images are reconstructed on an independent workstation with concurrent physician supervision.

What is CPT code 99347?

CPT Code 99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: o A problem focused interval history; o A problem focused examination; and. o Straightforward medical decision making.

What is CPT code 99251?

The Current Procedural Terminology (CPT®) code 99251 as maintained by American Medical Association, is a medical procedural code under the range - New or Established Patient Initial Inpatient Consultation Services .

What is the CPT code 74018?

CPT® 74018 in section: Radiologic examination, abdomen.

What does CPT code 71046 mean?

CPT® Code 71046 in section: Radiologic examination, chest.

Can CPT code 71045 and 71046 be billed together?

The 71045 CPT code can be billed for chest x ray single view, the 71046 CPT code can be used to report two views....Chest X-Ray CPT Codes 2016 vs. 2018.Deleted Chest X-Ray CodeNew Chest X-Ray CodeCPT 71015Replaced by CPT 71045CPT 71020Replaced by CPT 710467 more rows

What is the CPT code 74181?

CPT® Code 74181 in section: Magnetic resonance (eg, proton) imaging, abdomen.

What is the CPT code 70553?

CPT® 70553 in section: Magnetic resonance (eg, proton) imaging, brain (including brain stem)

What is the CPT code 76376?

Diagnostic imaging Current Procedural Terminology (CPT) code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound) has been opened for provider type 20 (Physician, M.D., Osteopath, D.O) to bill with dates of service on or after February 1, 2019.

What are the sections of a radiology report?

Radiology reports contain four main sections: clinical indications. technique. summary of findings. impression and final interpretation. The clinical indications listed on the report should be those signs or symptoms provided by the referring physician that prompted the ordering of the test.

What is a radiology test order?

2. The Diagnostic Test Order. An encounter for radiology services begins with a test order from the referring (ordering physician) which is then taken to an imaging center, hospital or other provider of diagnostic imaging services. A complete and accurate test order is crucial to coding compliance because payment for services by Medicare is made ...

What is post payment review?

Although many claims are being paid when initially submitted, post payment reviews are resulting in providers having to return monies to Medicare and other third-party payers.

Why is a patient referred for an abdominal ultrasound?

A patient is referred for an abdominal ultrasound due to jaundice. After review of the ultrasound, the radiologist discovers the patient has an aortic aneurysm. The primary diagnosis is jaundice and the aortic aneurysm may be reported as a secondary diagnosis. A patient is referred for a chest x-ray because of wheezing.

When is a diagnostic test ordered?

Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms. When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code.

Is incidental for one patient and one study?

What is considered incidental for one patient and one study, may not be considered incidental for another patient and another study. When there is difficulty in determining whether or not a finding is incidental or whether or not it should be reported, it is prudent to query the radiologist.

Can an uncertain diagnosis be coded?

If the referring physician provides a diagnosis preceded by words that indicate uncertainty (e.g., probable, suspected, questionable, rule out, or working), the uncertain diagnosis should not be coded.

When will xrays be reviewed?

February 1st, 2019. It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and technical component.

Do you pay for a re-read of an x-ray?

As a general rule, payers only pay for the technical and professional components of an x-ray just once. When a provider who did not perform or review the original x-ray reviews the image and writes up an interpretation of it, it is referred to as a re-read. When considering the proper coding of an x-ray re-read, ...

Do physicians pay for xrays?

As a general rule, payers only pay for the technical and professional components of an x-ray just once.

Can you report a xray to a physician?

If a patient presents to an office for a new patient visit and brings to the physician his or her medical records, including x-rays, you should not report code 76140. Although the x-rays may have been taken elsewhere, the physician does not perform a consultation as intended by code 76140. Rather, the review or re-read of ...

What happens if a procedure is not discussed in a radiology report?

If the procedure performed is not discussed or mentioned in the radiology report, then coders will not be able to code for that procedure and auditors may not be able to confirm that the procedure was performed.

When a mammogram is performed, should the left side be documented?

When the study performed is a bilateral screening or diagnostic mammogram, both the left and right side should be documented as having been performed or evaluated - either in the technique, findings, or assessment section of the report, regardless of the findings.

What is CPT code 76140?

Other carriers and third-party payers may have different guidelines and may recommend the use of CPT code 76140 (Consultation on X-ray exam made elsewhere, written report). As noted in the American Medical Association’s Principles of CPT Coding, if a patient comes to an office for a new or established visit and brings the physician his ...

Why is it important to share coding issues with radiology staff?

Because coding and radiology departments often share accountability for the quality of outpatient radiology coding, it is important that coding professionals share coding issues and charge capture expectations with radiology staff. This article outlines methods to improve the quality of coded data from radiology services ...

What is the source document for radiology?

Source documents for radiology coding include physician orders, a list of exams electronically generated from the organization’s registration or radiology system, or dictated reports. In many cases, the most important piece of documentation—reason for exam related to diagnosis—is often missing.

What is the 2009 Office of Inspector General Work Plan?

The fiscal year 2009 Office of Inspector General Work Plan will continue the review of payments for diagnostic x-rays in hospital emergency departments to determine the appropriateness of payments. This decision is based on March 2005 testimony before Congress that reported increasing costs of imaging services for Medicare beneficiaries and potential overuse of diagnostic imaging services. 3

When is it appropriate to obtain the information directly from the patient or the patient's medical record?

On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient's medical record if it is available.

What would cause me to code a sign or symptom as opposed to a definitive diagnosis?

The only circumstance that would cause me to code a sign or symptom as opposed to a definitive diagnosis is if the physician excludes the diagnosis from being the source of the patient's pain.

Why can't I code pneumonia?

I would not code the pneumonia because it is incidental to the abdominal pain. ICD-9 states that signs and symptoms that are associated routinely with a disease should not be coded when present. Abdomen pain is a routine symptom of diverticulosis. I hope this helps.

When a physician/QHP reviews the actual images produced by an external imaging center or facility, if they document

When a physician/QHP reviews the actual images produced by an external imaging center or facility, if they document their personal interpretation and findings, they would qualify for points under the Medical Decision Making (MDM) Data element of the E/M service they are reporting. They should not report modifier 26 in this scenario, as the contracted provider or staff radiologist at the imaging center should be paid for performing those services.

What does a doctor look for in an x-ray?

A physician who specializes in certain conditions (e.g., pulmonology, cardiology, orthopedics) may look for very specific characteristics of an x-ray which may not be commonly noted by the radiologist on staff who provides the original interpretation.

What is the Medicare Physician Fee Schedule?

The Medicare Physician Fee Schedule (MPFS), as published by CMS, includes 10 indicators that identify whether a test includes one or both the professional and technical component; almost all imaging services contain both.

What is 76140 in medical?

Remember, 76140 represents a consultation, in which a physician only renders an opinion or gives advice regarding the film in the form of a written report. In general, when reporting 76140, the physician is not concurrently providing an E/M face-to-face service to the patient.

What is an overread x-ray?

These are often referred to as an overread. A physician may be asked to provide a second opinion of an image alone or of a patient’s overall condition. This occurs frequently in liability cases such as injuries sustained at home, at work, or in an automotive accident. This re-reading of an x-ray is often referred to as a re-read.

When to add modifier 77 to EKG?

Add modifier 77 to the professional component of an x-ray or electrocardiogram (EKG) procedure when the patient has two or more tests and/or more than one physician provides the interpretation and report. As you can see, there are very limited circumstances in which modifier 77 may be reported along with modifier 26.

Do radiographs have to be intraoperative?

While these radiographs are intraoperative, they must still include a professional component and are often sent to the contracting radiology group for that purpose. While the professional component is bundled into the operation and not separately reported, the work must still be completed.

Diagnostic Test Order

An encounter for radiology services begins with a test order from the referring (ordering physician) which is then taken to an imaging center, hospital, or another provider of diagnostic imaging services.

Choosing the Primary Diagnosis

As per ICD-10-CM official guidelines, for patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.

Radiology Report

While the test order may determine medical necessity and initially drive the encounter, a review of the final radiology report holds the key to determining the correct diagnosis codes for an encounter. Radiology reports should contain four main sections: clinical indications; technique; summary of findings; and impression and final interpretation.

Documentation for Diagnosis Code

At first glance it may appear that diagnosis coding for diagnostic radiology exams is straightforward, it actually can be quite challenging. In many cases, the documentation that must be reviewed prior to assigning a diagnosis code may be unavailable, unclear, or contradictory. There are two key documents for review.