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Radiology Billing and Coding: Best Practices and Changes for 2019

October 4, 2018

Radiology Billing and Coding

Radiology billing and coding is often seen as cumbersome. It’s tough to stay up-to-date on all the individual payer changes and regulation changes. Billing and coding inconsistencies easily occur in the hectic radiology environments, and the disconnect that occurs may lead to under-coded or lost charges, as well as a high risk of dealing with compliance issues. Since many errors are only found when audits are performed or claims are denied, it’s difficult to figure out how much revenue your practice could be losing if your billing and coding practices aren’t up to par. Here’s a closer look at some tips that can keep your billing and coding processes on track so your practice receives the payment it’s entitled to and you’re able to concentrate on your passion for radiology.    

Tips for Radiology Billing and Coding 

Tip #1 – Focus on Clarity and Consistency in Documentation 

Proper billing and coding involves everyone, not just the billing and coding department. It’s essential for radiologists to focus on clarity and consistency in their documentation so it clearly identifies clinical indications, the exam that was performed, impressions, and findings. Documentation needs to be concise and clear, using language that is close to the CPT descriptors for valid related codes. A few tips for the best reports include:  

  • Don’t list exam titles in the impression or findings section.
  • List clinical indications separately from findings and impression. 
  • Exam titles need to have the elements for correct assignment and should include modality, views, anatomical site, and whether any contrast was used. 
  • Keep exams succinct. 
  • Ensure that exam and clinical indication don’t use any nonspecific, unfamiliar, or ambiguous terms or abbreviations. 

Tip #2 – Radiologists Must Maintain a Working Knowledge of CPT Code Requirements 

Radiologists are responsible for the codes that are submitted and the final documentation. It’s very common for dictated notes to not clearly support or match the ordered exam title, which results in coders either pursuing clarification from the radiologist or making assumptions with the incomplete data they were giving. Remember, coding isn’t just for coding staff. Radiologists must have a working knowledge of current CPT code requirements as well. 

Tip #3 – Provide Complete Documentation for a Complete Exam 

When a “complete exam” is done, you need to provide complete documentation to support that study. For example, if code 76700 is claimed for a complete abdomen study, then you’ll need documentation of the gall bladder, liver, spleen, common bile ducts, kidneys, upper abdominal aorta and inferior vena cava, and pancreas. Forgetting to document any one of these required anatomies means that you’ll have to down code to the limited exam, code 76705. The same holds true for any other “complete” studies being done. 

Tip #4 – Only Report Documented Views

The number of views that you claim has to meet the basic requirements of the CPT code that you report. The medical report has to state the number of views, and a good coder will need to count those views and then choose the right CPT code. For example, there are four different CPT codes for a knee exam. If you report a knee exam with four or more views, code 73564, then the documentation submitted must substantiate that four or more views were done. 

Radiology Billing and Coding Changes for 2019

One of the most important steps you can take to reduce denials and improve practice revenue is to stay up to date on the radiology billing codes and guidelines. Here’s a closer look at some of the anticipated changes for 2019

Fine Needle Aspiration Codes

You can expect to see the deletion of code 10022 and a revision to code 10021 for fine needle aspiration. Since fine needle aspiration code 10022 was found to be reported along with code 76942 over 75% of the time, it’s been recommended for bundling. Expect to see some new codes that bundle fine needle aspiration with radiological interpretation and supervision. 

Knee Arthrography 

Code 27370 for the injection of contrast for knee arthrography was noted as a potentially misvalued service. It’s often been incorrectly reported as aspiration or arthrocentesis, and it’s up for deletion this year. It will likely be replaced with a new code that reports the injection of contrast for CT/MRI knee arthrography or knee arthrography. 

Addition of Codes for Magnetic Resonance Elastography 

Currently, there’s no CPT code available for a magnetic resonance elastography (MRE), which is a newer diagnostic imaging technology. Expect to see a new code to report this service for 2019. 

Breast MRI with CAD 

The deletion of codes 0159T, 77058, and 77059 has been proposed, and these codes will likely be replaced with four new codes for breast magnetic resonance imaging. There will be two codes for reporting a breast MRI both with and without contrast, as well as two codes that bundle in computer-aided detection (CAD). 

Outsourcing Offers an Excellent Radiology Billing and Coding Solution 

Accurate radiology billing and coding practices have the power to increase your number of successful claims exponentially and reduce denials. With accurate coding, your radiology practice gets accurate charges for every patient. On the other hand, inaccurate, sluggish coding can keep back up your revenue cycle with costly denials. For this reason, many radiology practices find that outsourcing offers an excellent radiology billing and coding solution. Working with qualified billing and coding professionals can maximize revenue and take the burden of in-house billing and coding off your practice. 

At M-Scribe, we specialize in providing medical billing services to practices across the country. If you’re ready to reduce denials and improve revenue, we can help. Contact us today at 770-666-0470 or email me at to learn more about how we can provide you with radiology billing and coding solutions that help your practice thrive. 


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