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Pediatric Radiology

, Volume 48, Issue 7, pp 904–914 | Cite as

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

  • Chul Y. Chung
  • Mark D. Alson
  • Richard DuszakJr
  • Andrew J. Degnan
Review

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.

Keywords

Billing Coding Current Procedural Terminology Health insurance Pediatric radiology Reimbursement 

Abbreviations

APMs

Alternative payment models

CHIP

Children’s Health Insurance Program

CMS

Centers for Medicare and Medicaid Services

CPT

Current Procedural Terminology

HCPCS

Healthcare Common Procedure Coding System

ICD-10-CM

International Classification of Diseases, Tenth Revision, Clinical Modification

MUE

Medically Unlikely Edits

NCCI

National Correct Coding Initiative

PTP

Procedure-to-Procedure

RVU

Relative value unit

Notes

Acknowledgements

The authors acknowledge the kind assistance of: Maria Tran, RCC, CPC of the American College of Radiology in providing coding source material and manuscript review; A.J. Hernandez, RCC, CPC, and Kevin A. Grant, RCC, CCS-P, CIRCC of the ACR in reviewing the manuscript, Ellen Coffee and Poulinia Winrow of Radiology Associates of Children’s Hospital in providing institutional coding information and insight on coding practices, and Lynn Rader of Children’s Hospital of Pittsburgh in providing practical information on coding practices.

Compliance with ethical standards

Conflicts of interest

None

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Chul Y. Chung
    • 1
  • Mark D. Alson
    • 2
  • Richard DuszakJr
    • 3
  • Andrew J. Degnan
    • 4
    • 5
  1. 1.Department of RadiologyUniversity of Pittsburgh Medical CenterPittsburghUSA
  2. 2.Sierra Imaging AssociatesClovisUSA
  3. 3.Department of Radiology and Imaging SciencesEmory University School of MedicineAtlantaUSA
  4. 4.Department of RadiologyPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaUSA
  5. 5.Department of RadiologyChildren’s Hospital of PhiladelphiaPhiladelphiaUSA

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