Preparing a radiology practice for ICD-10 is challenging. Why? Not only must we educate and prepare our radiologists to provide the level of detail required by ICD-10 coding, but we must also make sure that our referring physicians are prepared to provide the same level of detail when they order a radiologic exam.
Since radiologists are dependent on the referring physician for pertinent information related to an ordered exam, they may be prone to thinking that ICD-10 coding is not their problem. What our radiologist must understand is that the referring physician is equally dependent on them. The treating physician must be able to document and code from our radiologic findings.
Keep in mind that for outpatient coding (Medicare Part B), the diagnosis code is assigned based on positive findings in the radiology report. When the finding is not definitive or negative, the code is assigned based on the diagnosis provided on the order (the indication). If the information provided in the indication and/or the finding sections of the final report are unspecific, assigning a diagnosis code for the procedure will be difficult or
impossible in ICD-10 coding.
Greater specificity will be needed in radiology reports to assign ICD-10 coding
to the findings. Details such as specific anatomical location, the severity or
acuity of the condition, the context, and the story of the patient’s condition
must be included in the radiology report.
It is time for radiologists to commit to ICD-10 and ICD-10 coding and embrace training opportunities that will help them prepare for this inevitable change.
Sharon Roeder, CPC
Manager of Payer Coding and Compliance
ICD-10 and ICD-10 coding vRad expert