HOW TO BRIDGE THE GAP BETWEEN CLINICAL DOCUMENTATION AND CODING DOCUMENTATION
If you think doing interventional radiology procedures can be varied and complex, try coding them. Just as the procedures you perform can include different techniques and cross multiple systems with countless variations, so do the codes. The CPT Code book has six surgical chapters and each chapter has its own unique set of instructions. Unlike other specialties who have a relatively narrow list of codes neatly found in a single chapter or two, interventional radiology procedures span the entire surgical section. Due to the breadth of the procedures that can be performed, coding interventional radiology cases is by far one of the most complex and challenging areas.
Details, Details, Details: So, how are the codes assigned? Throughout my career as an interventional radiology coder, I have found it commonplace for providers to mistakenly believe that their professional code assignments only come from a charge slip, which is usually outdated, or, worse yet, from an electronic feed of codes generated by the hospital. Professional coding simply cannot be done that way. It’s the details you provide within the report that determines the code assignments. The challenge becomes knowing which details to provide. The objective of this article is to show you where these details can be found.
Know Your Audience: It is also important to remember that your audience extends beyond the referring physician. Coders, auditors, and payers are looking for a match between the codes assigned and what was documented. All too often the clinical language just doesn’t sync up with the coding requirements. So why is there a difference? Three main reasons:
Key Steps to Successful Documentation: Documenting for coding purposes is not always intuitive. To be successful, knowing the specifics of what to document for accurate coding is key. Embrace this opportunity to bridge the gap between clinical documentation and coding documentation by following these 3 basic steps:
1. METHODICALLY REVIEW THE CPT CODE DESCRIPTIONS FOR THE PROCEDURES YOU PERFORM AND TAKE NOTE OF THE DETAILS
As an example, review the description for CPT 77001. Notice what is required: “…and radiographic documentation of final catheter position.” Because coders typically don’t have the access and training to review saved images, to meet this requirement, you would need to identify the final catheter placement by naming the final vessel catheterized and that an image was obtained confirming the placement.
77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiologic documentation of final catheter position)
2. REVIEW CPT CODING GUIDELINES FROM OFFICIAL SOURCES
In addition to the individual code descriptions, there are other official sources that should be reviewed.
Indeed, there is quite a bit to review but before you contest, throw your hands up in the air, walk away and say, “I didn’t sign up for this”, ASK for your coder’s assistance to encapsulate what you need to know. Each of these sources contain a wealth of information. For your financial success, it is paramount to take heed of your coder’s guidance.
3. MAKE SURE YOUR REPORT IS UNDERSTOOD
Clarity and certainty are essential. You can do the most complex interventions, but if the descriptions of the procedures are shoddily-constructed, reimbursement can be reduced or even eliminated. Proper use of grammar and punctuation is a necessary part of understandable communication.
Financial success requires correct coding derived from clear, accurate and complete radiologist documentation. But sometimes, there can be a disconnect between clinical understanding and coding documentation. To alleviate this, review the CPT coding descriptions for the procedures you perform and take note of the details required. In addition, review coding guidelines from other official sources for added clarity. Your coder can help you understand and internalize this information. Lastly, make sure your description of the procedure performed is complete and clearly stated.
Wendy Block, CPC, RCC, CIRCC
Senior Coding Advisor
111 Stow Avenue, Suite 200
Cuyahoga Falls, Ohio 44221