Radiology involves numerous detailed procedures and evolving technologies, making coding particularly challenging. One source reports that mismatched CPT/ICD coding and payer discrepancies can cost practices an average of about $85,000 per year in lost revenue. Leveraging medical coding services are a practical way for radiology practices to ensure accurate coding. Given the high exam volumes, frequent CPT updates, and strict payer rules around medical necessity and modifiers, radiology coding is especially vulnerable to audit findings.
Below, we examine the goals of radiology coding audits, steps involved, common errors uncovered, and key audit tips to strengthen compliance.
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What are Radiology Coding Audits?
Radiology coding audits are systematic reviews of clinical documentation and claims that verify whether medical codes and modifiers accurately reflect the imaging services provided.
Radiology involves multiple imaging modalities (MRI, CT, X-ray, ultrasound), each with specific coding nuances. Errors such as missing prior authorization, wrong modifiers, or incomplete records lead to higher denial rates and delayed payments. By validating radiology coding compliance and adherence to payer rules, these audits help hospitals and radiology groups prevent underbilling and overbilling, reduce audit risk and penalties, improving both revenue cycle management (RCM) and regulatory compliance. Through internal and external reviews, they improve overall radiology coding and billing processes.
AAPC distinguishes between different types of radiology audits:
- Focused vs. random audits: Focused audits target a specific service, procedure, specialty, or provider, while random audits review a representative sample of claims selected at random.
- Internal vs. external audits: Internal audits are conducted by in-house staff, whereas external audits are performed by independent third parties.
- Prospective vs. retrospective audits: Prospective audits review claims before submission to correct documentation or coding issues early. Retrospective audits assess claims after billing to verify reimbursement accuracy, recover underpayments, and refund overpayments to avoid penalties.
Radiology Coding Audit Goals
Radiology coding is a complex process. Basically, audits evaluate coding compliance by evaluating a sample of coded claims. Auditors evaluate clinical documentation and medical claims information and give feedback to providers and their coding team to mitigate risks and improve RCM. The main goals of radiology coding audits are to:
- Identify documentation gaps and inconsistencies that affect coding accuracy
- Evaluate the quality and accuracy of CPT, ICD-10-CM, and HCPCS coding
- Assess coding strengths and pinpoint areas requiring improvement
- Detect payer-specific reimbursement and policy compliance issues
- Uncover potential fraudulent billing practices, whether intentional or inadvertent
- Identify undercoding, overcoding, unbundling, and inappropriate modifier usage
- Educate radiologists, coders, and billing staff on correct coding and billing practices
- Establish and strengthen an ongoing quality assurance and monitoring process
- Mitigate compliance risks and reduce exposure to Recovery Audit Contractor (RAC) audits
- Ensure ongoing compliance with payer guidelines and federal and state regulations.
Common Radiology Coding Issues Identified in Audits
Common radiology coding audit findings include documentation deficiencies, incorrect modifier usage, coding mismatches, and noncompliance with payer-specific guidelines.
- Incorrect CPT code selection
- Improper use of modifiers
- Medical necessity mismatches
- Unbundling of radiology services
- Missing or incomplete documentation
- Errors in interventional radiology coding
- Duplicate or overlapping billing
These errors can trigger payer refunds and future claim scrutiny. By identifying them, audits help providers leverage data to improve coding, and enhance care quality while improving compliance and reimbursement.
Steps in the Radiology Audit Process
There are several key steps involved in the medical audit process, which should be defined during the planning stage, as noted by MGMA. These foundational steps also apply to radiology coding audits and include the following:
- Define the audit type and high-risk focus areas based on internal trends, RAC activity, or CMS guidance.
- Determine the sample size and whether the audit will be prospective or retrospective.
- Establish the audit period (e.g., one week, month, quarter, or fiscal year).
- Select and review the appropriate number of claims.
- Evaluate provider documentation for accuracy and compliance with policies and procedures.
- Track findings using a spreadsheet or audit tool that supports clear, reportable results.
- Present findings, educate staff and providers, and update policies and procedures as needed.
- Conduct follow-up reviews to confirm corrective actions and maintain quality assurance
Essential Information to Verify
AAPC instructs that the following information should be verified when auditing radiology services:
- Patient demographics: Patient first and last name, date of birth, etc.
- Date of service (DOS) and time
- Indication/Reason for visit: Verify the reason for the visit and make sure the appropriate ICD-10 codes are assigned (refer to your payer policy such as a local coverage determination (LCD) or national coverage determination (NCD), if necessary).
- Procedure header: Make sure that the procedure header supports the body of the report. For example, if the header supports a three-view X-ray, but the body of the report supports a four-view X-ray, AAPC recommends using the body of the documentation to support services billed.
- Techniques used: Verify the services (CT, MRI, etc) rendered, number of views, and with or without contrast.
- Procedure details: Check procedure details (image quality, limited or complete study, procedure complications, patient cooperation, recommendations, follow-up visit, etc.).
- Comparison studies: Review and compare the prior exam and previous images and reports with the current exam. Compare the details such as date, hospital, specialty provider details, reason for exam, etc.
- Findings/Impressions/Results: Make a summarized list of statements of the problem/condition (including features such as mass size, oval shape structure, etc) and result of the exam.
- Electronic signature: The signature should indicate “signed by” or “verified/reviewed by,” followed by provider name and professional designation.
- Supervision and interpretation: Ensure documentation substantiates the supervision and who provided the interpretation.
- Modifier use: Check modifier (Commonly used modifiers in radiology billing are 26, TC, 76, 77, 50, LT, RT, and 59).
Regular radiology coding audits help identify patterns of error, improve coder education, and strengthen documentation practices. They also ensure alignment with evolving CPT changes, CMS rules, and payer-specific billing policies—reducing denial rates and audit risk over time.
Radiology Coding Audit Tips to Improve Compliance
- Stay current with coding guidelines: Radiology coding guidelines—including CPT and ICD-10-CM—are updated frequently. Ensure coders stay informed of changes to avoid outdated or incorrect code selection.
- Invest in ongoing training: Provide continuous education to keep coding staff aligned with evolving regulations, payer policies, and specialty-specific updates that impact radiology services.
- Implement regular audits: Conduct routine internal audits to identify and correct issues such as missed charges, undercoding, overcoding, and documentation gaps before payer reviews occur.
- Use the right technology: Leveraging AI medical coding tools and audit software improves accuracy, streamlines workflows, and supports consistent coding.
- Coder-provider collaboration: Open communication between coders and radiologists helps clarify clinical intent, resolve documentation questions, and support accurate code assignment.
- Ensure complete documentation: Accurate, detailed radiology reports are essential. Documentation must include clinical indicators that clearly support medical necessity, procedures performed, and any reportable findings.
- Monitor modifier usage: Apply modifiers correctly and consistently. Improper or excessive modifier use is a common audit finding and a frequent trigger for denials.
- Review bundled services carefully: Confirm that bundled services are correctly captured and that separately reportable services meet payer requirements for unbundling.
- Understand LCDs: Align coding practices with Medicare LCDs and payer-specific policies to ensure regional coverage and medical necessity requirements are met.
- Establish a coding compliance program: Develop a formal compliance plan that includes policies, training, audits, corrective actions, and ongoing monitoring to sustain long-term accuracy and compliance.
By maintaining a radiology coding compliance audit checklist based on these best practices and establishing and strengthening ongoing quality assurance and monitoring, radiologists can enhance accuracy, streamline operations, and ensure compliance with coding guidelines.
Radiology medical coding is a complex but crucial aspect of healthcare administration, leading radiology departments to rely on a specialized medical coding company to ensure accuracy. Leading companies provide AI-integrated radiology coding reduces audit risk by aligning CPT and ICD-10-CM codes with imaging documentation, validating modifier use, and flagging payer-specific issues before claims submission. This proactive approach helps prevent denials, overpayments, and audit exposure while maintaining compliance, which ultimately benefit both providers and patients.
Reduce denials with comprehensive radiology coding audits and compliance support.
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