When documenting your vascular interventional radiology procedures, it is important to remember your audience extends far beyond the referring physician. On a regular basis, your report is scrutinized by a multitude of non clinical staff such as coders, auditors, billers, payers, and medical reviewers to name just a few…

What they are looking for is an exact match between your documentation and the code(s) submitted.  And if the procedure you performed has the potential for high reimbursement, the more likely you can count on it to be challenged.

Does your documentation clearly describe the procedure performed?  The purpose of this newsletter is to provide a few tips to help you add clarity to your report for auditing and reimbursement purposes.

BACKGROUND – HOW YOUR REIMBURSEMENT IS DETERMINED
The purpose of coding is to provide a uniform language that will accurately describe the procedure(s) you performed and the reason(s) as to why it was medically necessary.  Simply stated, payers look at the diagnosis codes to determine if they should pay and then look at the procedure codes to determine how much to pay. But keep in mind, there are rules that have to followed, there has to be a match between your documentation and the code(s) assigned.  Instructions for use of the CPT Codebook states “Select the name of the procedure or service that accurately identifies the service performed.  Do not select a CPT code that merely approximates the service provided.”  Because of this requirement, it is important to review the CPT code descriptions for the procedures you perform and remember to use language that mirrors the code descriptions. An auditor’s job is to make sure there is a match between your documentation and the code assigned.

CODING TERMINOLOGY MAY NOT BE THE SAME AS CLINICAL TERMINOLOGY – DON’T ASSUME YOU ARE UNDERSTOOD
Clinical documentation is well understood by the other physicians and generally, vascular interventional radiologists communicate very well peer to peer. Coders may know what you did but without it being documented they can’t code for it.  The concern is there may be a difference between what you actually did and what was billed out.

INTERVENTIONAL RADIOLOGY – DOCUMENTATION REMINDERS FOR CODING AND REIMBURSEMENT

Vascular Catheterizations

• By name, identify the access site(s), each vessel catheterized
• If catheter was placed through a previously placed sheath, include this information
• Specify left or right as appropriate
• Identify which system was catheterized (arterial, venous, lymphatic, portal)
• Catheter movement (antegrade, retrograde, ipsilateral, contralateral)
• Identify and describe abnormal anatomy
• If a prior diagnostic study was inadequate, patient’s condition with respect to the clinical indication has changed since the prior study be sure to include these details

Endovascular Repair of Aneurysm

• Describe the type of stent graft placed in addition to the commercial name, e.g., “… Endologix® unibody bifurcated stent graft was deployed.”
• Make the distinction between placing a second piece that completes the main body vs. a true extension
• If you are working as a co-surgeon, for each component of the procedure, identify who performed it, e.g., “From a right common femoral approach, I (alone) placed the catheter into the aorta,” and “The vascular surgeon and I placed the main body in the abdominal aorta.”
• Specify whether the access was percutaneous or by a cut-down

Supervision and Interpretation

Because supervision and interpretation procedures were designed to be spilt, it is important to indicate whether you were in the room providing fluoro only, or you were not in the room but did provide an interpretation of the images obtained, or if you did both. To better explain, see how the coding differs based on how you document the study.

Example:  In a facility setting, ERCP of the biliary ductal system was performed by another physician

Scenario 1: Documentation states you were in the room and provided fluoroscopic guidance
76000-26 ($8.95) Fluoroscopy only

Scenario 2: Documentation states you were not in the room but interpreted images
74328-26-52 ($18.08) Endoscopic catheterization of the biliary ductal system (Interpretation only)

Scenario 3: Documentation states you were in the room, provided supervision and interpretation
74328-26 ($36.16) Endoscopic catheterization of the biliary ductal system (Supervision and Interpretation)

(Note:  Fees provided are from the 2016 National Medicare Allowable)

Central Venous Catheters/Devices

Your documentation must include:

• Access peripheral insertion (e.g., basilic or cephalic vein) or central insertion (jugular, subclavian, femoral vein, IVC)
• Final catheter tip placement (subclavian, brachiocephalic, iliac vein,  SVC, IVC, right atrium)
• Tunneled or non-tunneled
• Description of the addition of a port or pump, if performed
• Specify whether it was an insertion, repair, partial replacement, complete replacement, or a removal

When ultrasound guidance is used, include all of the following:

• Evaluation of potential access site(s)
• Selected vessel patency
• Concurrent real-time ultrasound visualization of needle entry
• Storage of permanent images (either film or digital)

Fluoroscopic guidance requires:

• Use of fluoroscopy
• Contrast injections through the access site
• Images to confirm the final catheter position

SENTENCE STRUCTURE AND GRAMMAR STILL COUNTS

Don’t take shortcuts by leaving words out.  Your documentation doesn’t have to be long, just clearly written. Make sure your sentences are understandable and complete.  The proper use of grammar helps make your description of the procedure understandable.  Poor documentation leads to the wrong code assignments, insurance denials, and most importantly, potential patient harm if what you stated was misunderstood.

IN SUMMARY
Documenting for clinical care, proper coding, and reimbursement are equally important.  Many interventional radiologists believe their only audience is the referring physician and often fail to remember that there is a larger financial audience which includes coders, auditors, payers, and reviewers to name a few. Even though you know in detail the procedure you performed, unless it is clearly documented using language that matches the code description, it doesn’t count.  To remedy this, take a look at the CPT descriptions and mirror the terminology used.  The written radiology report is one of the most critical components of the services you provide.

If you have a documentation issue that you would like to see covered, please contact Wendy Block, CPC, RCC, CIRCC  at wblock@streamlinemd.com or by phone at 330.564.2618