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The transition to ICD-10 that took effect in October 2015 is progressing. Physician practices are submitting claims with the new codes quite successfully and getting reimbursed by insurers, many with the help of professional medical billing and coding companies. However, one specialty that faces unique reimbursement challenges following the switch to ICD-10 codes is radiology.

Radiology comprises sections such as diagnostic ultrasound, bone and joint studies, radiation oncology, and other fields. Services that come under diagnostic radiology include plain film radiography or x-rays, diagnostic ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), diagnostic nuclear medicine, positron emission tomography (PET), and mammography.

Changes in Medical Coding for Diagnostic Testing

Radiology practices are reporting problems due to the changes in reporting diagnostic testing under ICD-10. Converted local and national coverage determinations (LCDs and NCDs) are a major challenge for radiology medical billing.

Claims with unspecified diagnoses may occur in radiology. The Centers for Medicare & Medicaid Services (CMS) has confirmed that “when sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code.”

However, medical necessity guidelines have changed and all LCD information was not translated from ICD-9 to ICD-10, as it was assumed. What used to be covered in the ICD-9 LCD/NCD no longer meets the medical necessity in the ICD-10 LCD/NCD. In some cases, medical codes that are unspecific have been excluded. Examples:

  • An LCD for non-invasive abdominal and visceral vascular studies will cover abdominal pain of a specified site, but it will not cover unspecified abdominal pain (R10.9).
  • Another issue relates to denial of noninvasive peripheral venous study services when reported with leg/arm swelling under LCD L34229. Swelling, a typical symptom related to deep vein thrombosis (DVT), was approved under ICD-9 for diagnostic testing under LCDs. The ICD-10 code for leg/arm swelling is M79.89 (other and unspecified soft tissue disorders, not elsewhere classified), but after the LCD translation to ICD-10, M79.89 was omitted as it was unspecified/not elsewhere classified.
  • The NCD for bone density scans omitted the diagnoses for ‘osteopenia’ though this is a very common finding and reason for the test.
  • Incorrect denials under ICD-10 have been reported for chest X-rays, and CT / MRI of the head.

All these missing indications, which previously supported radiological studies, can significantly impact provider reimbursement, especially if the indications are a common symptom of a condition.

Reliable Radiology Medical Billing Company for Success with ICD-10

To address claim rejections with converted LCDs and NCDs, the American College of Radiology (ACR) has issued specific recommendations to deal with the problem. Partnering with an experienced medical billing service company can help radiology practices ensure adherence to these best practices, which include:

  • Close monitoring and comparison of current ICD-9 LCDs against the converted ICD-10 LCDs commonly performed
  • Ensuring early detection of any potential errors in the ICD-9 to ICD10 translation
  • Monitoring of volume of medical necessity and coding related denials
  • Checking for changes in LCD and NCD policies, including deletions and missing codes
  • Following existing procedures for correcting and resubmitting rejected claims and issues related to denied claims

Proper documentation from both the radiologist and the ordering physician is crucial for most specific ICD-10 codes. Professional medical coders in a medical billing and coding company will notify their clients about insufficient/missing clinical documentation before submitting claims and ensure that the ICD-10 code on a claim is a valid one. Moreover, they are also familiar with all payer rules, which can reduce denials.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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