Most radiology practices are currently feeling the pinch of deep reduction in imaging revenue and decreased volume. Based on an analysis of the change in imaging volume from Yale’s academic multi-specialty radiology practice, the group saw a 70 percent dip in outpatient imaging since the start of the COVID-19 crisis, including a 50 percent drop in emergent and inpatient services. Practices may anticipate a loss of revenue between 50 percent to 70 percent of their normal levels, by the time of the end of the COVID-19 crisis. In this article, we discussed 5 inefficiencies in radiology billing and coding, eliminating these could help to recover a major portion of revenue for your practice. In such a crisis what we can do is focus on current radiology billing practices and try to make them more efficient.
5 Inefficiencies in Radiology Billing and Coding
Pre-Authorization
As per a recent study report of Fathom, 12% of denials are related to authorizations and 90% of authorization-related denials are preventable. Before rendering the service, the radiologist must verify that prior authorization was obtained. Payers are continually increasing the list of procedures that will require pre-authorization. However, for numerous reasons, a different procedure may actually end up being performed than what was originally authorized. Unfortunately, that often only gets discovered once coding has been completed and it is too late to revise the authorization, or worse, upon notice of denial.
The absence of prior authorization may happen due to the absence of experienced medical coding and billing staff. The process for authorization must begin at the time of the patient’s registration for an appointment. The front office staff must gather as much information as possible about the patient’s condition and the reasons for the exam. All details are important, as it may be necessary for the radiology department or imaging center staff to contact the referring physician’s office. Also, the staff should verify that imaging orders are appropriate and complete. In some cases, it can be seen that the referring office will have obtained authorization from the insurance company.
Non-Specific Diagnosis Codes
In July 2015, the Centers for Medicare & Medicaid Services (CMS) announced that during the first year of ICD-10-CM, Medicare Administrative Contractors (MACs) would not deny claims based solely on the specificity of the diagnosis code. Many practices interpreted this as approval to ignore the specific ICD-10-CM codes and even today continue to report non-specific codes. Obviously, these facilities and practices are struggling to put processes in place to make sure that specific clinical indications are obtained. Consider an example of ‘injury.’ Instead of coding a non-specific injury code, the type of injury (contusion, sprain, laceration) or symptom (pain) should be documented and coded. Reports for imaging for injuries also should indicate whether the exam occurred during the initial treatment phase or subsequent healing phase or whether it is a sequela of a previous injury.
Incomplete Documentations for Complete Ultrasound Procedures
As per the same Fathom report, 12.6% of exams billed as complete do not contain sufficient documentation. Ultrasounds can be classified as complete or limited as indicated in the CPT® code descriptor. To bill for a complete examination, all items and organs listed must be imaged and described, or reason an organ is not imaged or described (i.e., organ surgically absent) documented.
For example, to bill for CPT® 76856 Ultrasound pelvic (non-obstetric), or real-time with image documentation; complete evaluation and measurement (when applicable) of the urinary bladder, evaluation of prostate and seminal vesicles (visualized transabdominal), and any pelvic pathology (bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess) must be performed. When radiologists fail to properly document complete procedures, your practice can miss out on anywhere from 20 percent to 50 percent of the potential reimbursement depending on whether you are billing global or just the professional component.
Missed Views
It is not always straightforward to capture the correct number of views by referring to a radiologist’s dictation leading to underbill for services. For example, in a knee exam, if the radiologist dictates anteroposterior, lateral, and oblique views on a knee, many coders will code a three-view study. However, given that there should be both left and right oblique views, it should actually be a four-view study.
Failing to Capture MIPS Codes
CMS estimated that MIPS performance could increase payments by 6.25 percent for 2020 with up to a 9 percent penalty, meaning the level of participation could represent more than a 15 percent swing in reimbursement, yet practices continue to struggle to ensure their codes are captured correctly. Even with clear guidelines in place, lack of training and a desire for coders to hit productivity metrics can leave these critical codes missed.
If you don’t have qualified manpower to handle radiology billing and put an end to radiology billing and coding efficiencies, don’t worry, we can assist you. We can assist you in eliminating these 5 inefficiencies in radiology billing and coding. When you outsource your radiology billing and coding, you get access to our billing and coding experts who have vast knowledge about diagnostic radiology coding and they understand payer rules. We use accurate codes to file claims and help practitioners to get reimbursed in a timely manner.
In this way, we can enhance the revenue stream and improve the cash flow. Our radiology medical billing services cover everything from eligibility verification to clean submission of medical claims to revenue collections. To know more about our radiology medical billing and coding service, contact us at info@medicalbillersandcoders.com/888-357-3226.
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