Radiology Coding in ICD-10: A Primer

When it comes to ICD-10, radiologists may be particularly vulnerable to denials if they don’t take the time to prepare. 

Why? These practices often depend on documentation from referring physicians who may or may not include the specificity necessary to justify medical necessity for a particular test, says Betty Hovey, CPC, COC, CPB, CPMA, CPC-I, CPCD, director of ICD-10 development and training at the American Academy of Professional Coders (AAPC). This is problematic today in ICD-9, and it will become even more troublesome in ICD-10 when the code set demands more specific information. Hovey says radiology practices should focus on obtaining more specific documentation for the following diagnoses:

1. Bone fractures. Referring physicians must document the following (Note: Some fractures don’t require all of this documentation, but many of them do):

Whether the fracture is pathological (include the underlying cause, if applicable) vs. traumatic

Specific anatomical site at which the fracture occurred

Type of encounter (i.e., initial, subsequent, or sequela)

Laterality (i.e., right vs. left)

Alignment of the fractured bone (i.e., displaced vs. non-displaced)

Open vs. closed fracture

Type of fracture

Healing (i.e., malunion or nonunion, or delayed or routine healing)

For example, the following diagnostic statement is appropriate for an x-ray performed for a patella fracture: Displaced longitudinal fracture of right patella, subsequent encounter for closed fracture with nonunion. For more information about fracture coding and documentation in ICD-10, visit the American Academy of Orthopaedic Surgeons’ Website.

2. Limb pain. In ICD-9, limb pain maps to code 729.5. However, in ICD-10, referring physicians must specify the specific limb, where the pain occurs on that limb, and whether it is the right or left limb. For example, ICD-10 code M79.632 denotes pain in the left forearm.

3. Abdominal pain. Referring physicians must document the specific location of that pain (i.e., right upper quadrant, left upper quadrant, epigastric, right lower quadrant, left lower quadrant, periumbilic, or generalized abdominal pain). Ask physicians to distinguish between acute abdominal pain, abdominal tenderness, rebound abdominal tenderness, colic, and pelvic pain.

4. Congestive heart failure (CHF). Referring physicians must document the type of heart failure (i.e., systolic, diastolic, or combined) and whether it’s acute, chronic, or acute on chronic. For example, ICD-10 code I50.32 denotes chronic diastolic congestive heart failure.

5. Osteoarthritis. Referring physicians must document the specific anatomical location as well as laterality. The American Academy of Orthopaedic Surgeons provides more information on how to code and document this diagnosis properly in ICD-10.

Ensuring compliance
To prepare for ICD-10, consider the following tips:

Know the practices from which referrals are obtained. Compile a list of all physician practices that refer patients to your radiology center. Contact each practice to explain the importance of documentation specificity in light of ICD-10. Payers will likely deny unspecified codes. Physician orders for tests should reflect the same level of clinical detail that’s included in the physician’s own chart at the practice.

Ask for the information you need. Consider designing an order template that prompts physicians to document specificity necessary for ICD-10. Share this template with all referring physicians, and require them to use it when completing orders.

Track and trend your data. Does a particular referring provider constantly demonstrate non-compliance, resulting in time-consuming follow-up and resubmission of claims? Reiterate to these providers that eventually, the radiology center may refuse their patients simply because the center is unable to get paid for the services it performs.

For more ICD-10 news, updates, and tools, visit the Kareo ICD-10 Resource Center.