Xray Orders and Coding Compliance

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Posts: 12
Joined: Thu Mar 29, 2018 8:55 am

Wed Oct 24, 2018 1:11 pm

Does the Xray Order have to match the Interpretation/Read and essentially what was billed for Clinic Xrays performed by ordering physician? Example) Provider in clinic orders xrays and reads them same day. He selected Xray Bilateral Standing AP Knees (73565) but in his interpretation he clearly indicates the view was actually PA view, not AP and does not meet CPT description 73565. Does the order/note need to be sent back for an addendum so that both the interpretation and the Order match? Or can the coder select the CPT code based off his Xray interpretation within the clinic note which would be 73560 and ignore the order issue?

Ive done some research on CMS and WPS websites and all I found was that CMS recently updated their policy that a signed order is not required for diagnostic Xrays paid in the physician fee schedule but his medical record must document the intent and medical necessity. Does this give us some leeway in orders matching what was billed based on supporting documentation? There was also an article by AAPC - Seven tips for diagnostic radiology coding success by John Verhovshek - that stated coders should bill Xrays based off the report of what was performed by adding the views themselves. It stated if the specific number of views were not listed then the coder should pick the lowest code. This article is fairly old and I did not see this in the CPT Guidance or CMS manual, so Im not sure if I feel comfortable using this as supporting documentation for following this process... is this information accurate and would it be compliant to do this without receiving an updated order?

Tue Dec 04, 2018 1:57 pm

Hi Gibbons,

The guidance we would give in Compliance is two folds:

1. Seek clarification from provider by having them update the note to reflect the radiograph report or the other way around...which ever is accurate...through an addendum. If that is not possible,

2. I would only code the facility component of the xray. I would not code the professional fee because I do not feel it is supported. If you code it one way, you would have not a valid order to support medical necessity. If you code the other, then you could be setting up yourself to submitting a fraudulent claim. I am reaching, but by definition, fraud is "knowingly and willingly submitting a claim that you know to be false." By that definition, I would be hesitant to do either.

By the way, I am more conservative than a risk taker.

Any other thoughts?
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