Things I Wish Every
By Melody W. Mulaik, MSHS, CPC, CPC-H, RCC, PCS, FCS
Everyone would like to believe that their
own facility or organization does everything correctly. I think in our heart of
hearts we know that is impossible since
every process includes humans and, as
humans, we will make mistakes. It is
important to separate true “mistakes”
from ongoing errors that cause incorrect
coding and billing practices. Ignorance is
no excuse in today’s complex regulatory
environment. As a radiology professional
you cannot just claim “I didn’t know” or
“that was not my responsibility.” If you are
responsible for radiology revenue and/or
compliance then you have the responsibility to ensure things are done correctly.
There are many areas where coding
and compliance concerns exist. Most of
these coding articles address specific areas
in detail. This article will highlight a few
key areas of concern frequently encountered in today’s auditing environment. All
of the regulatory guidance is not provided,
due to the lack of space, but it is my hope
that if you identify an area of concern that
you will review a previous issue of
Radiology Management or seek additional support and guidance as appropriate.
There are many non-physicians who per-
form radiology services and it is very
important that you understand the differ-
ence between what a person is allowed to
do clinically and what you are allowed to
bill for. In the radiology environment,
non-physician practitioners (NPPs) are
physician assistants (PAs) and nurse prac-
titioners (NPs). Radiology practitioner
assistants (RPAs) and radiologist assistants
(RAs), commonly referred to as extenders,
are NOT considered NPPs and may not be
treated as such under any circumstances.
While state guidelines govern clinical
scope of practice, billing guidelines are
governed by the national Centers for
Medicare and Medicaid Services (CMS).
Supervision guidelines must be met to
ensure compliance with CMS guidelines.
Also, just because a patient does not have
Medicare does not mean you do not have
to follow the CMS supervision guidelines.
Many of the private payor contracts spec-
ify that they will follow CMS guidelines so
you could be inadvertently violating indi-
vidual payor contracts.
Documentation Not Matching
The radiologist’s dictated report is what
supports the codes submitted for both
the facility and the physician practice.
Even though the facility has the images
on file, the documentation must support
whatever exam was billed to the insur-
ance payor. Many times there is a discrep-
ancy between the report and billed exam,
especially for the facility. In the event of
an audit the payor may demand a refund
based on the discrepancy. The most com-
mon problems are usually found in the
• Use of IV contrast for CTs
• Lack of documentation of 3D for CTA
• Missing number of views for plain
films (eg, just stating “complete,” which
does not translate into a specific num-
ber of views)
Arguably one of the greatest opportunities to improve correct charging lies
within interventional radiology services.
Most facilities still rely on the technologists to capture the charges. Sometimes,
the HIM coders assign the surgical codes;
however, it is rare that they venture into
assigning codes for imaging services.
Given the ever changing codes and guidelines for interventional services, it is a
great challenge even for an experienced
medical coder to ensure correct coding.
Most technologists that I know did not go