Tag: medical coder

Questions

Diagnostic Radiology Coding Questions?

Lindsay Della Vella

Hey Everyone,

For this weeks blog post, I thought I’d have you guys ask me questions. What questions do YOU have about diagnostic radiology coding? It can be about CPT, ICD-10, guidelines etc. Is there anything you’d want me to answer? Please post in the comments below or send me an email at midnightmedicalcoding@gmail.com.

I’ll post the questions and the answer in the blog post for next week.

 

Thanks!

 

 

 

 

 

 

 

 

 

Midnight Medical Coding Products You Might Be Interested In:

 

Learn The 50 Most Common X-Ray CPT Codes-

Self-paced online course. Getting awesome reviews from fellow coders.

 

 

 

15 Question Practice Coding Test

Practice coding the ICD-10-CM and CPT codes of HIPAA compliant X-ray reports. Answers and rationales provided.

 

 

 

 

 

Tabs for the ICD-10-CM Book: Get 60 printed, multi-colored, double-sided tabs. These can be used on any 2019 or 2018 ICD-10-CM book from any publisher.

 

 

 

 

 

 

 

 

 

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Diagnostic Radiology Coding Basics

10 Things You Need To Know Before Coding Diagnostic Radiology

Lindsay Della Vella

For this week’s post, I thought I’d talk about just some general things relating to diagnostic radiology coding.  Bear in mind, this isn’t the be-all-end-all, everything-you-need-to-know guide. This is just what I would tell a new coder who had limited experience with this specialty in a nutshell.

  1. First things first–radiologists can be vague in their documentation. They like to use words like “consistent with,” “probable,” “rule-out” etc.  In the outpatient setting–you do not code uncertain diagnoses. So if you come across a report with these terms, do not code it. A common phrase I see in the impression on chest x-rays is “consistent with pneumonia.” Since it is not definitive, you would not code the pneumonia–you would code whatever the symptoms are. There is a coding clinic however that states that the use of the words “Evidence of” is not a vague term–so you can code the condition.
  2.  When you’re coding, refer to the impression. If there is a finding, it will be listed here, and this is where you code from. If there are no findings, you would code the history/symptoms stated on the report.
  3. When you’re coding x-rays, you count up the number of views to get the CPT. Sometimes the radiologists may mention images–do not count images. It is not the same thing as views. (If you want to learn more about x-ray coding, don’t miss the boat on our online class).
  4. Another thing to keep in mind is to always follow all client specific guidelines. For example, do you code an addendum? Do you need to add a modifier 26? All of these types of questions will be answered in your client guidelines. (A good rule of thumb is to review your client guidelines before reaching out to the lead coder for questions).
  5. Know the difference between limited and complete ultrasounds (refer to the CPT book).
  6. Know the difference between all the different OB ultrasounds (refer to the CPT book).
  7.  CTA’s must state 3D in the documentation.
  8. Know whether or not you need to code the contrast for MRI and CT scans. Do you code contrast waste? Again, review client guidelines on these types of questions.
  9. Know whether or not you need to code incidentals. The answer to this is generally no, but this is another client guideline type question.
  10. Last but not least, know how to code fractures. If this is new to you, see this previous blog post.

So there you have it. Hopefully this list helped you figure out a little more about diagnostic radiology coding.

Thanks for reading-

 

 

 

 

 

 

 

Midnight Medical Coding Products You Might Be Interested In:

 

Learn The 50 Most Common X-Ray CPT Codes-

Self-paced online course. Getting awesome reviews from fellow coders.

 

 

 

15 Question Practice Coding Test

Practice coding the ICD-10-CM and CPT codes of HIPAA compliant X-ray reports. Answers and rationales provided.

 

 

 

 

 

Join the Midnight Medical Coding Stars- A membership only area where one HIPAA compliant diagnostic radiology report is added each week for you to code the ICD-10-CM and CPT codes. Answers provided.

 

Join the Midnight Medical Coding Stars

 

 

 

 

 

 

Tabs for the ICD-10-CM Book: Get 60 printed, multi-colored, double-sided tabs. These can be used on any 2019 or 2018 ICD-10-CM book from any publisher.

 

 

 

 

 

 

 

 

 

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CAC

Will CAC (Computer Assisted Coding) Replace Medical Coders?

Lindsay Della Vella

So, here’s a question I see posted in different FB groups every once in a while–Will CAC (Computer Assisted Coding) ever replace medical coders? There is a long and short answer. The short answer is No. The longer answer–still No, but there’s more to it than meets the eye.

We all know there are some computer programs out there that make coding easier. These programs pick up on key words in documentation and for lack of better word–the computer ‘codes’ it. But here’s the thing-computers may be good at picking up on key words, but they can’t think. Computers are not aware of coding rules and guidelines, modifiers, excludes 1 notes…etc. So what happens is, the CAC just codes whatever keywords it picks up on, but it may be all wrong because it doesn’t know the rules. Here is what I mean:

Sometimes, it codes the reason for the exam plus the findings. According to ICD-10-CM coding guidelines, that is incorrect. When there are findings that explain the reason for the exam, the report is coded to the finding. Another thing I’ve seen CAC software do is put about 5 or 6 diagnosis codes on a simple report, like an abdominal ultrasound. It’s not wrong per se, but really? Do we need to code every single incidental diagnosis? No. Incidentals don’t need to be coded, but I’ll save that for another post.

Here is another common mistake that I’ve seen on audits done by CAC software. If you’ve coded radiology, you know how radiologists love to say “consistent with.” So, say you’re coding a chest x-ray and the report says, “findings consistent with pneumonia.” According to ICD-10-CM Coding Guidelines, you would not code the pneumonia because it is not definitive (this is outpatient coding, by the way. Inpatient coding has different rules on this). Many times the CAC software picks up on the word “pneumonia” and codes it. That is not how that report should have been coded because of the “consistent with.” It would be coded to the symptoms or a definite finding in the report. So, like I said earlier, CAC does not think. Does not know coding rules.

My guess is though (and this is only a guess) is that maybe in the future, most coders will be just checking the codes that CAC software came up with, and having more of an auditing role. Many places use CAC and have success with it, but there are also people checking the codes before it goes out. At the end of the day, there will always be a need for coders. Coders do way more than assign codes based on keywords. We think and have an in depth knowledge that just can’t be replaced by a computer. Besides, would any doctor out there want their billing/coding not even checked by a qualified person before it goes out? Probably not.

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Midnight Medical Coding Stars

Practice Report To Code

Lindsay Della Vella

Everyone knows that coding takes practice, right? I mean it would be really nice if we just woke up one day, and knew how to code all the different specialties. (I admit I still have nightmares about learning how to code E/M).

 

Looking back, I remember a teacher I had who used to say, “The more you practice, the better you get.” That couldn’t be more true when it comes to medical coding. If you don’t practice EVER, you just won’t become familiar with certain types of reports. The problem is though–practice reports are hard to come by. There’s not too much out there, especially for diagnostic radiology coding.

But have no fear–I have reports that I can share. Each one is a diagnostic radiology report (x-rays, ultrasounds, ct, cta, mri, mra, duplex) For each one, you code the CPT and ICD-10-CM code, and then check your work. I am always available for questions–feel free to email me (midnightmedicalcoding@gmail.com).

So, everyone get a pencil and piece of paper if you’re old school like me, or use a tablet/device to take notes on.

For this report, please code the CPT and ICD-10-CM code.

**These reports are HIPAA compliant and do not contain PHI.

Ready for the answers? No cheating…

 

 

So, did you get the right answers? It’s okay if you didn’t. Remember–all types of coding take practice. Want to have a shot at practicing radiology coding? The good news is–I have more practice reports available! Each week I post a new report for you to code. Right now there are 20 reports available immediately and a new one will be added each Monday.

Join the Midnight Medical Coding Stars. That is a membership-only area where I post all of the reports.

 

I can’t just share these reports with the whole world. This is special and it’s reserved for only certain people. It is only $4.99 per month. That is a steal. That’s less than 1 Starbucks coffee.

 

I hope you’ll join us!

 

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Coding Course

My First Day Working As A Medical Coder

Lindsay Della Vella

On the first day of my first coding job, I didn’t know what I was doing. I really didn’t. I never coded a real radiology report before. I guess I read a few in my coding classes, but it was something that wasn’t focused on.

Everything I knew about radiology was just based on my life experiences up to that point. I knew what a wrist x-ray was because I needed one before (broke my wrist rollerblading). I knew what an ultrasound was because I have kids and had my fair share of prenatal ultrasounds.

I kind of knew what an MRI was because the machine looked scary to me and I couldn’t see myself ever being brave enough to go in one if needed. I didn’t know what a CT was. Never heard of a CTA or MRA. Didn’t know what spectral doppler was. Needless to say I was confused at my first coding job. I didn’t know what any of this stuff was. I was fortunate enough to have an awesome mentor who helped me with CPT coding and even some diagnosis coding here and there.

But I know not everyone is as lucky as I was. Not everyone has a mentor. Or maybe you don’t feel comfortable asking a coworker for help. Even though I’m not a new coder anymore, I didn’t forget what it was like being new. How I was afraid of coding everything wrong. How I was afraid that I really did not know what I was doing and was not going to make it as a coder.

 

Some of you may know this already–but I’ve put together a new diagnostic radiology coding course. It is geared towards new radiology coders or coders in another specialty who want to learn more about it. It focuses on the CPT coding of x-rays. By the time you finish the course, you will know how to code the CPT for a variety of x-rays. You will be familiar with 50 of the most common ones used and will be prepared for ‘real life’ diagnostic radiology coding. It is all online and self-paced.

Please see the link below for a full description of the course. You’ll see the exact format and what is included. Scroll down the page and you will see a FAQ section and what my students are saying about the class. I hope you’ll join us!

 

Click Here for more info, to see class reviews and to sign up!

 

Click HERE for more info, to see class reviews and to sign up.

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Coding Course

On Sale Now!

Lindsay Della Vella

Are you a medical coder or medical coding student who wants to learn more about diagnostic radiology coding?

There are A LOT of codes in the CPT book and you’re probably only familiar with the ones you use everyday.

So, if you’re a coder in another specialty, or a coding student, you might not know that much about the CPT coding of x-ray’s just because you haven’t had the opportunity to code them yet, or maybe it’s something that really wasn’t focused on in your regular coding classes.

Our new online coding class is available now! It focuses on the CPT coding of x-rays. You will code HIPAA compliant reports after each lesson and do coding practice exercises, take quizzes (your score is available immediately after submitting it) and there is test at the end. Supplemental info/sources/links are also provided. It is all online and self-paced.

The instructor (me- Lindsay Della Vella!) is available 24/7 through email for questions.

This class is getting excellent reviews from fellow coders who have already completed it. I hope you join us!

It is on sale NOW for $39.99! Offer expires Sunday at 5 pm EST.

Click the link to sign up and for more info.
https://bit.ly/2wSf6hF

Still have questions? Feel free to email me at midnightmedicalcoding@gmail.com

Coding Course

Diagnostic Radiology Online Coding Course

Lindsay Della Vella

Midnight Medical Coding will be offering an online diagnostic radiology coding course starting in January 2019! This course focuses on x-ray CPT coding. You’ll learn the most common codes, how to look them up in the book and you’ll practice coding HIPAA compliant reports.

The course is done at your own pace and I’m always available for questions. There’s 9 modules (may ultimately end up being 10) which includes videos for instruction, pdf downloads, quizzes and practice coding exercises.

Students will also have the option of joining a private Facebook group just for people who take this course. That is where I can always be reached and I’ll also be sharing supplemental materials there. It also will be a place for students just to connect and talk to each other.

I’m super excited about this! Cost is $50.00 and you will have access to the course to December 2019.

If you want to stay in the loop and be notified when this course becomes available please go to: https://midnightmedicalcoding.podia.com/intro-to-x-ray-cpt-… and sign up for updates.

x-ray class cover

coding challenge

Coding Challenge 5

Lindsay Della Vella

Please code the ICD-10-CM and CPT code for this report. To check your answers, click the link at the bottom of the report.

ABC Hospital

Patient Name- Jon Doe

Date- 1/1/18

Referring Dr- Dr Smith

Exam- US Renal

—————————————————————————————————————–

Procedure- US Renal

History- Routine check of renal cysts

Technique-2D images

Findings- Complete evaluation of the right kidney. Right kidney is normal in size with no hydronephrosis. No calculus. Simple cyst measuring 1.4 x 2.1 x 3.6 located mid portion. Simple cyst #2 measuring 1.7x 1.9 x 1.6 located upper pole.

RT kidney retroperitoneal measurements- length 9.71 AP 5.04 cm. width 5.52 cm

Complete evaluation of the left kidney. The kidney is normal in size with no hydronephrosis. Complex cyst measuring 2.2x 1.2x 1.5 located mid portion. Visualized portion of the IVC are normal. Proximal and abdominal aorta obscured by bowel gas.

LT kidney retroperitoneal measurements- length 11.50 cm AP width 6.25 cam

The bladder is normal.

Prostate is normal.

Impression- No hydronephrosis. Bilateral renal cysts.

Signed by Dr Michaels 4:00 pm 1/1/18

Go here to check your answers!

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