A Step-by-Step Guide on Coding of Radiology Reports

Medical coding for radiology and billing in radiology can be challenging because of the critical nature of diagnostic imaging and the importance of accuracy in assigning codes. To prevent a claim denial due to coding, it's essential to learn the core of medical coding. This guide takes you through the most efficient steps on coding radiology reports so it is considered an excellent starting point for the beginners.

‍

Key Sections of a Radiology Coding Guidelines

Before embarking on coding, it is helpful to become familiar with the general elements of a radiology report. Typically, most reports have several common sections:

1. Header. This section contains the patient's name, date of birth, medical record number, the name of the imaging facility and the date of the study. For inpatient examinations, the admitting diagnosis could also be included.

2. Ordered Procedure: It can be simply referred to as the title, describing what the exam was ordered by the referring physician. Some of the examples would include "CT Sinuses without contrast," "Right Knee 4 views," and more.

3. Indications: The section indicates why the patient is getting an exam. These include descriptions from a patient or the referring physician such as "Chronic Sinusitis," "Knee pain," and "Chest pain.".

4. Technique: This section indicates how the examination was carried out, such as "Chest AP and Lateral" or "Right Knee, AP, lateral, both obliques and swimmers view."

5. Findings: This is the interpretation of the radiologist on the images taken including any abnormalities or normal results.

6. Impression: This is the final opinion by the radiologist based on the findings, that could be a specific diagnosis or an abnormality that cannot be assigned to a diagnosis.

‍

Step-by-Step How to Create an Accurate Radiology Report

Understanding the details offered in the radiology report begins the process of accurate coding. These steps ensure coding accuracy:

Step 1: Study the Indications

The first step in coding is to examine the indications, or the reason for the exam. Understanding why the exam was performed helps ensure that only relevant conditions are coded. For example, if the indication is "right lower quadrant pain" and the findings show lumbar spondylosis and acute appendicitis, the primary diagnosis should be "acute appendicitis." The incidental finding of "lumbar spondylosis" should not be coded.

Step 2: Impression Review

Review the impression or conclusion section. This will indicate what the final diagnosis was on the basis of the imaging findings. Only confirmed diagnoses should be coded, especially in outpatient settings. Diagnosis that are not confirmed with such terms as "possible" or "suspected" should not be coded. When the impression is positive and it states that there was no abnormality found, code the reason for the exam that is the indication, as the final diagnosis.

Step 3: Review the Results

Review the results section to include specificity or to find more diagnoses that are relevant to the exam performed. Only the findings that are relevant to the primary indication or exam should be coded.

Step 4: Choose the Primary Diagnosis Code

The main impression would then represent the principal diagnosis made based on the information available concerning the rationale for the procedure. For instance, when the indication is "Right knee pain," but the impression made is that of "right knee osteoarthritis," then the secondary diagnosis code must express "right knee osteoarthritis."

Step 5: Assignment of Secondary Diagnosis Codes as Primary Radiology Coding Rules

Any other important conditions or circumstances which may influence reimbursement like the relevant medical history should also be reported as secondary diagnoses. For instance, in case the patient has malignant neoplasm of the left lung and there's also a note on the medical record that a history of smoking exists, then such information about the smoking history should appear on the list of the patient's secondary diagnoses.

Step 6: Determine Limitations of Local Coverage

It's also important to verify through the local MAC that the CPT codes for radiology and ICD-10 code selected is covered prior to filing claims. Medicare only covers services that are considered reasonable and necessary to diagnose or treat a condition. Also, make sure that the primary diagnosis of this patient is covered by the payer.

Conclusion

Mastering the art of coding radiology best practices is important for ensuring timely, accurate reimbursement for diagnostic imaging services. Following these steps and focusing on key sections of the report will streamline the process, avoid errors, and reduce claim rejections.

Do you need help with your radiology coding and billing? Partner with O P O, a leader in medical billing services, to streamline your revenue cycle management. Our expert team uses cutting-edge tools and technology to ensure coding accuracy, minimize denials, and enhance your practice's profitability. Contact O P O today to learn how we can optimize your coding processes and improve your bottom line.

‍