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

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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.

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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

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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.

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Authors and Affiliations

  1. Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Chul Y. Chung

  2. Sierra Imaging Associates, Clovis, CA, USA

    Mark D. Alson

  3. Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA

    Richard Duszak Jr

  4. Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Andrew J. Degnan

  5. Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA

    Andrew J. Degnan

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  1. Chul Y. Chung
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  4. Andrew J. Degnan
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Correspondence to Andrew J. Degnan.

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Chung, C.Y., Alson, M.D., Duszak, R. et al. From imaging to reimbursement: what the pediatric radiologist needs to know about health care payers, documentation, coding and billing. Pediatr Radiol 48, 904–914 (2018). https://doi.org/10.1007/s00247-018-4104-1

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