Documentation for Interventional Radiology
Many interventional radiologists believe their only audience is the referring physician and fails to remember that there is a larger financial audience which includes medical coders, insurance carriers, auditors, and reviewers to name a few. Even though you know in detail the procedure you performed, unless it is clearly documented using language that matches the code description, it doesn’t count. To remedy this, take a look at the CPT descriptions and mirror the terminology used. The written radiology report is one of the most critical components of the services you provide. Documenting for clinical care, proper coding, and reimbursement are equally important. We have provided a comprehensive list of documentation to be kept for interventional radiology procedures.
- By name, identify the access site(s), each vessel catheterized
- If the catheter was placed through a previously placed sheath, include this information
- Specify left or right as appropriate
- Identify which system was catheterized (arterial, venous, lymphatic, portal)
- Catheter movement (antegrade, retrograde, ipsilateral, contralateral)
- Identify and describe abnormal anatomy
- If a prior diagnostic study was inadequate, the patient’s condition with respect to the clinical indication has changed since the prior study be sure to include these details
Endovascular Repair of Aneurysm
- Describe the type of stent graft placed in addition to the commercial name, e.g., Endologix® unibody bifurcated stent graft was deployed.
- Make the distinction between placing a second piece that completes the main body vs. a true extension
- If you are working as a co-surgeon, for each component of the procedure, identify who performed it, e.g., from a right common femoral approach, I (alone) placed the catheter into the aorta,’ and ‘The vascular surgeon and I placed the main body in the abdominal aorta.’
- Specify whether the access was percutaneous or by a cut-down
Supervision and Interpretation
Because supervision and interpretation procedures were designed to be spilled, it is important to indicate whether you were in the room providing fluoro only, or you were not in the room but did provide an interpretation of the images obtained, or if you did both.
Central Venous Catheters/Devices
Your documentation must include:
- Access peripheral insertion (e.g., basilic or cephalic vein) or central insertion (jugular, subclavian, femoral vein, IVC)
- Final catheter tip placement (subclavian, brachiocephalic, iliac vein, SVC, IVC, right atrium)
- Tunneled or non-tunneled
- Description of the addition of a port or pump, if performed
- Specify whether it was an insertion, repair, partial replacement, complete replacement, or a removal
When ultrasound guidance is used, including all of the following:
- valuation of potential access site(s)
- Selected vessel patency
- Concurrent real-time ultrasound visualization of needle entry
- Storage of permanent images (either film or digital)
Fluoroscopic guidance requires:
- Use of fluoroscopy
- Contrast injections through the access site
- Images to confirm the final catheter position
Documentation must support medical necessity and procedure codes.
The purpose of coding is to provide a uniform language that will accurately describe the procedure(s) you performed and the reason(s) as to why it was medically necessary. Simply stated, payers, look at the diagnosis codes to determine if they should pay and then look at the procedure codes to determine how much to pay. Note that, there has to be a match between your documentation and the code(s) assigned. Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. Because of this requirement, it is important to review the CPT code descriptions for the procedures you perform and remember to use language that mirrors the code descriptions.
Pay attention to documentation language
Don’t take shortcuts by leaving words out. Your documentation doesn’t have to belong, just clearly written. Make sure your sentences are understandable and complete. The proper use of grammar helps make your description of the procedure understandable. Poor documentation leads to the wrong code assignments, insurance denials, and most importantly, potential patient harm if what you stated was misunderstood. Clinical documentation is well understood by the other physicians and generally, radiologists communicate very well peer to peer. Coders may know what you did but without it being documented they can’t code for it. The concern is there may be a difference between what you actually did and what was billed out.
MedicalBillersandCoders (MBC) is a leading outsourcing medical billing company that can assist you in radiology billing and coding. We are a HIPAA compliant company providing complete revenue cycle solutions to radiology practices. To know more about our radiology billing and coding services, contact us at firstname.lastname@example.org/ 888-357-3226