This article is a reprint of a piece originally published in the RBMA Bulletin.
I am not a coder, but I have been involved with revenue cycle processes for a few decades. At the beginning of my career, we received all billing information from the facility on paper—demographics in one batch and dictated radiology reports in another. They were hand-sorted and matched before going to the coder. For even amid-sized practice, that was a full-time job and it automatically imposed a lag time in the billing process, especially when at the end of the day there always remained a stack of demographic reports without an accompanying radiology report—due to waiting for comparison studies, timing (end of the day, for example) or even misplacement.
It was a time for large stacks of paper. Everywhere. The matchers had stacks, the coders had stacks that moved on to become charge entry stacks. Insurances correspondence was stacked up until someone had time to follow up. Same with denied claims. Stacks of checks and explanation of benefits forms (EOBs) were handed to payment posters. Payments that could not be identified were stacked for follow-up. All of this paper was eventually filed and stored on site, where it could be retrieved for appeals and answering questions. There were attempts to maintain orderly files, usually by site and date of service, but those seeking information knew to look at file dates preceding and following the date you were seeking. Errant info was often just misfiled so checking further was routine.
My early attempts to facilitate the coding process involved hiring entry-level employees to match and/ or track down missing information. That enabled the coders to focus on their key mission-coding. They were paid more per hour due to their subject matter expertise and it only made sense to have the more expensive employees with specialized knowledge focused on the task requiring specialized knowledge.
Documentation was another challenge and it was the wild west of dictation, with every radiologist adopting his/her own style. Ultrasound needed complete documentation of specific organs? You hoped the radiologist remembered or maybe worked with notes attached to the workstation as a reminder. Codes were usually hand-written on the radiology report and cryptic notes may (or may not) have supported decisions made. Those cases requiring additional documentation with the claim were…stacked, so someone could collect them, photocopy the reports and mail the complete claim to the insurance plan. Perhaps this helps explain why 60 days in A/R was considered a pretty decent performance.
When we look at how technology has automated even simple documentation gathering and storage tasks, those initial time-consuming processes seem laughably primitive. Granted there are still digital “stacks” in billing computer worklists but there is no comparison in terms of workflow management. Today’s coder sees the demographics and reports side by side on the screen and benefits from automation and access to resources.
Coding: The Early Years
Claudia Murray, RCC, RCCIR, FRBMA asked, “Did you know at one time Medicare coded fee tickets submitted by physicians?” Claudia began working for Medicare as a summer intern and ended up staying for 20 years before becoming a recognized coding expert, compliance consultant and popular speaker for RBMA meetings. She started before the introduction of diagnosis codes and recalled contacting a physician for clarification when the indication for most of his procedures was “GOK” and she was unfamiliar with the acronym. He responded that it meant “God only knows.” She said, “Lord knows how many claims were paid by Medicare with that diagnosis.” Murray also noted, “There were no CPT (Current Procedural Terminology) codes in the early years and we used 4-character codes to identify procedures.”
Her comments about the early years of coding were affirmed by Renee Engle, RCC, RCCIR, MSN-ARC, FRBMA, and President of the Radiology Coding Certification Board (RCCB) who stated, “I started coding back when V72.5 Radiology Exam was all that was needed as a diagnosis to get a claim paid. You applied the CPT and V72.5 and magically the claim was paid. Coding was simple before the carriers started utilizing the diagnosis to decide if you would be paid. The CPT was straightforward and you coded based on the ‘most’ accurate CPT to what was being performed. Yes, that was before Unlisted CPT codes. The onset of ICD-9 diagnosis codes made coding more difficult. You coded CPT based on the documentation and identified the ICD from the dictated report “bottom up,” beginning with the impression with the goal of getting the highest level diagnosis code with the greatest specificity.”
She continued, “In 1992 we had to learn a whole new language, or it seemed like it. The entire interventional radiology (IR) section of the coding manual was revamped with orders of vessels. Prior to that a four vessel study was one code, then it became 6-7 codes depending on the family of vessels, with the highest order of each for the surgical component and the radiology supervision and interpretation for the rest. It was a huge learning curve. Fast forward to today when ICD-10 brought a whole new meaning to coding to the highest level of specificity and CPT re-bundled IR and special procedures. It often feels the insurance carriers are using every tactic to avoid payment for claims and many will no longer reimburse for ‘unspecified’ diagnoses codes.”
Both referenced the fact early radiology coding involved a “heads down” production environment and fatiguing manual processes.
The best coders develop a relationship with their groups or clients to establish two-way communications. They serve as a resource on documentation requirements, denial trends and intimately know coding rules and regulations.
Recognizing Professional Status
For many years Walt Blackham, RCC, RCCIR was the face of radiology coding for RBMA members, who eagerly awaited his annual update sessions. Blackham conducted a series of coding education seminars and toured nationally to present updates, classes on medical terminology and to help RBMA members master the basics of interventional radiology.
After observing that existing national coding certification exams included only a few radiology-specific questions, he encouraged the RBMA to develop a coding certification to address the complexity of radiology coding. The Radiology Coding Certification Board (RCCB) was launched in 2000 after an intense developmental phase that met strict accreditation guidelines based on appropriate psychometric procedures. The nature of the program required that the RCCB function independently from the RBMA as a separate and independent organization, since the latter would continue offering coding and compliance educational programs.
The status of Radiology Certified Coder (RCC) recognizes proficiency in procedure coding, medical terminology, regulations and professional ethics. It involves qualifying to take the exam through a rigorous application process, passing the exam and then maintaining a continuing education program.
Matthew Wenger, Executive Director of the RCCB, noted the organization added a credential for interventional radiology (RCCIR) in 2018 and began offering international testing, primarily in India, in 2019. The RCCB has approximately 700 certificants, recognizing elite status in a demanding profession.
Life in the Coding Fast Lane
When asked about the required skills and demands on coders today, Engle responded, “Being a coder is no longer ‘heads down code it until you drop.’ It is the lifeline of a radiology group. If you don’t get coding right, you don’t get anything right and don’t get paid. Practice leadership also needs to realize compliance is of the highest importance. Documentation must support the CPT and ICD codes submitted on the claim. In addition, you must be aware of the many different carrier guidelines in order to ensure a claim is medically necessary and reimbursed.” She continued, “A coder must also function as a communicator with the radiology provider, sharing the guidelines and requirements for a documented report.
The best coders develop a relationship with their groups or clients to establish two-way communications. They serve as a resource on documentation requirements, denial trends and intimately know coding rules and regulations. As radiology providers became very sub-specialized, the coders have also. It is very difficult to be proficient in all modalities. Coders must also know and understand governmental rules and regulations to support their coding.”
Murray emphasized the importance of coders as effective analysts and communicators. She commented, “They routinely communicate with physicians/providers, management, operations and information technology so there is an emphasis on analysis, problem-solving, written communications and computer skills. On top of maintaining a current knowledge of coding and the impact of changes, they need to understand healthcare policy and regulations. There is significant liability with poor coding practices so ongoing communication regarding accuracy is critical.”
In Conclusion
Radiology coding serves as an excellent illustration of how our specialty has rapidly evolved with the advances in technology, the introduction of new modalities, expanding regulations, health plan medical policies and subspecialization. It can sometimes feel like a whole new world every year and change is the only constant. Expectations placed on professional coders have elevated their importance in the revenue cycle and all indications are the demands will continue.
Prior to joining MSN Healthcare Solutions as Director of Education and Corporate Communications, Pat Kroken had nearly 30 years of experience in radiology management as both a practice manager and consultant to radiology groups, billing companies, software vendors and hospital radiology departments.
Pat has had more than 200 articles published, is a regular contributor to the Radiology Business Management Association (RBMA) Bulletin and a frequent speaker on practice management topics. She served two terms as President of the RBMA, is Editorial Advisor for the national RBMA publication, The Bulletin, and represented the “business side of radiology” as RBMA Liaison to the Radiological Society of North America (RSNA) Associated Sciences Consortium for 7 years.
