The Need to Communicate with Your Referring Physicians
One goal of radiologists is to ensure that radiologic examinations are appropriate for the clinical problems. Clearly, this is in the best interest of the patient and the referring physician and results in the most cost-efficient imaging care delivery. However, coding and reimbursement problems sometimes occur when the study performed is not exactly that which was ordered. The ACR believes, and has argued to the Health Care Financing Administration (HCFA), that radiologists should have the authority to modify an order/referral for a radiologic procedure, provided that the study's report or patient's medical records contain the rationale for the change. Educating your referring physicians on this matter is critical in minimizing these problems while maximizing the efficiency of patient care delivery.
Two common examples of radiology studies where there is often a difference between the referring physician's understanding of the requested study and the actual performance of the clinically appropriate study involve computerized axial tomography (CT) of the abdomen (CPT codes 74150, 74160, 74170) and CT of the pelvis (codes 72192, 72193, 72194), and ultrasound of the abdomen, complete (code 76700) and limited (code 76705).
CT of the Abdomen and Pelvis. In many, if not most practices, requests for CT examinations are previewed and tailored to the clinical indications. These protocols stipulate what anatomical areas need to be imaged in order to answer the clinical question. On the other hand, the CPT codes for CT are based on specific body sites. Therefore, a protocol involving several areas may result in the use of several CPT codes. Adding to the confusion, many referring physicians do not understand the distinction between a CT of the abdomen (74150-74170) and a CT of the pelvis (72192-72194) and frequently do not distinguish these in their request. As a result, the procedure ordered and the subsequent coding may not match.
For example, radiologists are often referred patients with instructions to assess, evaluate, or rule out metastatic or lymphatic spread in the abdomen. In order to determine the extent of the disease, the radiologist may find it medically necessary to use CT to scan not only the abdomen but also the upper pelvis.
For those instances when an abdominal CT scan is continued through the upper pelvis, the recommended manner of billing would be to submit a CT abdomen code (74150-74170) and a CT pelvis code (72192-72194) with either the reduced service modifier (-52) or a limited CT (76380) and to charge accordingly. Consult your carrier for the most appropriate method. However, when two full studies are done, the two full codes should be reported without the -52 modifier. Each procedure should be appropriately documented.
Abdominal Ultrasound. A referring physician requiring a sonogram of the liver and gallbladder may order a complete abdominal sonogram. However, according to the ACR's Standard for the Performance of the Abdominal and Retroperitoneal Ultrasound Examination, a complete examination of the upper abdomen would include the liver, gallbladder and biliary tract, pancreas, spleen, and limited views of both kidneys, which is clearly more extensive than necessary for the clinical circumstance. Consequently, a clinical problem focusing on two organs in the abdominal area may warrant only a limited abdominal ultrasound (code 76705). In this example, the referring physician is likely to be unaware of the distinction between these ultrasound codes and should be educated by the radiologist on the appropriate study to be ordered.
Radiologists, either directly or indirectly, should work with their referring physicians to eliminate any ambiguity over the procedure ordered. In doing so, the referral justifies the coding. With increased frequency, third-party payers are looking for inconsistencies between the study ordered versus the one billed. In addition, communication with the referring physician may help avoid situations where a payer may deny one or both procedures. Radiology practices should also communicate that accompanying diagnoses, signs, and/or symptoms are necessary so that the appropriate ICD-9 coding may be assigned. According to the ACR Standard for Communication Diagnostic Radiology, "in order to promote optimal patient care and enhance the cost-effectiveness of each diagnostic examination, radiologic consultations should be provided and radiographs interpreted with appropriate clinical information. The ACR supports all efforts to obtain clinical data with each consultation request."
There is a variety of literature available that can be used to educate and communicate with your referring physicians. For example, the ACR's standards can be used to define the organs covered in a particular exam. The Appropriateness Criteria can be used to show which procedures are more appropriate than others for a given clinical condition. A systematic review of referrals may demonstrate areas of ambiguity. With the aid of scheduling software, your scheduler can ask the specific questions which can lead to the correct study being ordered.
The above studies should be documented and performed in accordance with the ACR Standard for the Performance of the Abdominal and Retroperitoneal Ultrasound Examination, the ACR Standard for Computed Tomography of the Abdomen or Pelvis, and the ACR Standard for Communication Diagnostic Radiology.
