Chest X-ray coding in 2018

Chest X-ray coding has become simpler in 2018, the chest x-ray codes are some of the most frequently used imaging codes in healthcare.

Previously Chest X-ray codes used nine different codes, now these nine codes have been replaced with four codes that are simply determined by the number of views.

As  the new Chest X-ray codes are coded based on the number of views, from a documentation compliance standpoint it is imperative for the practice to ensure that the different types / number of views are appropriately documented.

The new Chest X-ray codes are,

• 71045 Radiologic examination, chest; single view
• 71046 Radiologic examination, chest; 2 views
• 71047 Radiologic examination, chest; 3 views
• 71048 Radiologic examination, chest; 4 or more views

ICD 10 - Improving Clinical Documentation

ICD-10 is finally here and what most of us do not realize is that, it is just not enough that we are able to code in ICD-10 and get the claims billed out, we need to ensure that the documentation is specific and supportive of the ICD-10 diagnoses billed.

We need to make sure that our clinical services are documented in greater detail, so that the documentation supports a more specific ICD-10 code. Physicians / staff  involved in creating the documentation need to become more accustomed to the specific, detailed clinical documentation needed to assign ICD-10 codes.

For example, laterality is expanded in ICD-10-CM. Therefore, clinical documentation for diagnoses should include information about which side of the body is affected (i.e., right, left, or bilateral).

Some of the Clinical parameters that we need to document as per the diagnosis/condition, in order to be able to code in ICD-10-CM are,

        Clinical Documentation Parameters:

• Onset - when did it start
• Manifestation - Paralysis, Loss of Consciousness
• Comorbidities
• Etiology/Causation - Infectious agent, Physical agent, Internal failure, Congenital
• External Causes - Motor vehicle, Injury, Assault, Accidental, Work related, Intentional Self harm
• Complication
• Detailed Anatomical Location - Proximal, Distal, Medial, Lateral, Central, Peripheral, Superior, Inferior, Anterior, Posterior
• Functional Impairment
• Biological & Chemical Agents
• Phase/Stage
• Lateralization /Localization - Rt side, Lt side, Bilateral or Unilateral
• Severity - Mild, Moderate or Severe
• Time Parameters - Intermittent, Recurring, Postoperative, Postdelivery
• Encounter type - Initial, Subsequent
• Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

Below are some examples of the specific information that would have to captured and documented to accurately code the following common diagnoses in ICD-10:

        Diabetes Mellitus:

• Type of diabetes
• Body system affected
• Complication or manifestation
• Long-term insulin use

        Fractures:

• Site
• Laterality     
• Type - open, closed
• Encounter type - Initial, Subsequent   
• Healing Level - Routine healing, Delayed healing, Non-Union, Malunion e.t.c

        Injuries:

• Place of occurrence
• External cause - Cause of injury, how the injury happened
• Activity code - what the patient was doing at the time of the injury ?
• External cause status - Injury related to military, work or others

It will be important to make your documentation as detailed as possible, since ICD-10-CM gives more specific choices for coding diagnoses. This information is likely already being shared by the patient during the encounter, it is a matter of capturing all the pertinent information so that we can choose the most appropriate ICD-10 Dx. Proper documentation helps to reduce denials and increase compliance.

E&M Coding & Documentation Guidelines

It is essential that we code and document every patient encounter accurately so as to maximize revenues and avoid potential audits and recoupments later. It is imperative that we document all procedures that are performed. Any procedure that is not documented would be considered as not performed by the payors.

While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently  documented the progress note  to support the required level of History and Physical Exam.

For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines

Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation

Another scenario for the same patient would be wherein,  we have documented more than what is needed, let us assume that we have documented  a Detailed History and a Detailed Exam and have billed  CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.

Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals  on Coding and Documentation.   http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html

Signing of Medical Records

Medical Records need to be signed once the services are rendered, the medical record is authenticated when a Provider signs the document.

Payers expect records to be signed within 24 Hrs after services are rendered. In the case of EHR, the records need to be signed electronically.

Medical records that are not signed and records that are signed after a unreasonable delay may not be accepted and could lead to financial and legal implications.

Importance of Documentation

Medical Documentation is very important from a Clinical, Financial and Legal standpoint. 

From a Clinical perspective medical documentation establishes the following,

• the Patient receiving the Service
• the Physician providing the Service
• the Plan of Care provided by the Physician
• the Diagnosis justifying Medical necessity
• the Procedures performed, the Labs ordered
• the Quantity of Service such as consumables
• other details such as Place of service / Date of service e.t.c

From a Financial perspective medical documentation establishes the following,

• proper adjudication of claims
• timely payment of claims

From a Legal perspective medical documentation establishes,

• the justification for the procedures performed
• Legal protection for the Patients and Physicians

The Physician / Provider has to document all the procedures performed and sign the document, procedures that are not documented would be considered as not performed and would not be eligible for payment.