Radiology Coding Guidelines

Coding guidelines are used in the medical profession to accurately identify disease and treatment in a hospital facility. Used in medical documentation, codes record all activities related to patient treatment. As a quick way to document medical activity for insurance and hospital compliance, radiology coding guidelines are used by radiology coders to assist in ensuring documentation meets universal health standards in radiological practice.

ICD-9-CM Coding

• The ICD-9-CM is a comprehensive data table that includes a list of disease codes, an alphabetical index to disease entries and a classification of medical procedures. It is overseen by the National Center for Health Statistics (NCHS) to ensure codes are updated as needed. The International Classification of Diseases (ICD) is used to code and classify mortality data from death certificates. Clinical Modification (CM) is used to code and classify morbidity data from patient records, doctor's offices and NCHS surveys. The number nine in the coding title indicates the number of times the system has been revised by the World Health Organization.

What Are Coding Guidelines?

• Coding guidelines are an essential part of the medical process as they assist the health care provider and coder in ensuring accurate complete documentation on a patient's assessment, proper diagnosis and treatment. ICD-9-CM health care coding guidelines are provided by the Department of Health and Human Services (DHHS). Rules that accompany instructions provided in the ICD-9-CM, these guidelines follow the sequencing instructions included in the multiple volumes of ICD-9-CM instruction, providing additional instruction on assigning ICD-9-CM diagnosis and procedure codes required under the Health Insurance Portability and Accountability Act (HIPAA).

Coding Guideline Contents

• The ICD-9-CM coding guidelines provide indexed sections designed to give health care practitioners a tool to understand code conventions. They assist in identifying the etiology of coding based on disease and treatment, proper inclusion or exclusion terms and abbreviation. If used correctly, health practitioners can ensure proper code input on patient documents. Sections included in the guidelines are: conventions and code guidelines, selecting principal diagnosis, reporting additional diagnosis and reporting guidelines for outpatient services.

Radiology Coding Guidelines: Initial Assessment and Diagnosis

• In radiology practice, coding is important and can present coding challenges to those responsible for ensuring diagnostic coding is accurate. In Radiology Today, an online publication for radiology professionals, 10 guidelines were singled out as especially important in radiology diagnostic coding. Basic radiological identification guidelines include: the allowance of signs and symptoms as diagnosis when a formal diagnosis is not confirmed, using combination fracture codes only as a last resort and the acceptance of abnormal test results as acceptable diagnosis when other tests are negative.

Radiology Coding Guidelines: Treatment and Confirmed Diagnosis

• Treatment and Sequence code guidelines include ensuring the correct sequencing of diagnoses in radiation treatment programs. Screening codes should be correct as well as the confirmation of proper coding once a formal diagnosis (post testing) has been issued. For treatment of serious health conditions like cancer and cardiovascular disease there are critical guidelines like reporting primary treatment of secondary neoplasm sites for radiation therapy and ensuring cerebrovascular accident (CVA) or stroke are correctly coded to ensure the event severity and treatment steps are properly noted. Most importantly in radiology coding, it is essential that the health care practitioner understands the items and detail and needs to be documented for HIPAA.

Radiology Coding Certification

• To meet the growing development of radiology treatment and technological advancements in devices and procedures using radiological practice, the American Academy of Professional Coders (AAPC) created a certification for professional coders working in radiology. The Certified Interventional Radiology Cardiovascular Coder (CIRCC) certification provides additional education and expertise to radiologist and cardiovascular coders. To sit for the certification exam, you will possess an associate's degree and a letter of recommendation from the employer or physician. You will bring ICD-9-CM codes and supporting materials and possess current membership with the AAPC. (Reference 4)