From imaging to reimbursement: what the pediatric radiologist needs to know about health care payers, documentation, coding and billing

Abstract

Medical coding and billing processes in the United States are complex, cumbersome and poorly understood by radiologists. Despite the direct implications of radiology documentation on reimbursement, trainees and practicing radiologists typically receive limited relevant training. This article summarizes the payer structure including the state-based Children's Health Insurance Programs, discusses the essential processes by which radiologists request and receive reimbursement, details the mechanisms of coding diagnoses using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and imaging services using Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, and explores reimbursement and coding-related issues specific to pediatric radiology. Appropriate documentation, informed by knowledge of coding, billing and reimbursement fundamentals, facilitates appropriate payment for clinically relevant services provided by pediatric radiologists.

A systematic review of outpatient billing practices

“…Chung et al 17 discuss medical coding and billing in pediatric radiology. This study points out that improper documentation and coding can lead to patients’ families receiving unexpected and unnecessary bills that could cause financial hardships.…”

“…If documentation is missing components that directly relate to the level of coding, there is potential for the billing claim to be denied, resulting in loss of reimbursement. 17 In addition, complete documentation provides a means to measure quality of care, predict clinical outcomes, and anticipate future patient needs. 16 Due to concerns about potential fraud with upcoding, 4 physicians may be inclined to under code.…”

Does prophylactic inferior vena cava filter reduce the hazard of pulmonary embolism and mortality in severe trauma? A single center retrospective comparative study

“…Thromboembolic event data identified in the registry were crosschecked with medical records in order to validate findings. This was done either automatically with computational extraction algorithms (demographics, ICD-9 codes, Current-Procedural-Terminology-Codes) or by free text search of medical records [9][10][11]. All positive endpoints identified by the trauma registry were confirmed by physician chart review.…”

Prophylactic placement of inferior vena cava filters and the risk of death or venous thromboembolism in severe trauma patients: a retrospective study comparing two hospitals with different approaches

“…This was done either automatically with computational extraction algorithms (demographics, ICD-9 codes, Current-Procedural-Terminology-Codes) or by free text search of medical records. [11][12][13] All positive endpoints identified by the trauma registry were confirmed by physician chart review.…”