Exploratory Study of Radiology Coding in Health Information Management Practice

Two hundred seventy-eight surveys were used for data analysis purposes. Sites reported that on average they have 3.4 coders devoted to radiology coding who code an average of 4,245 reports per month. Productivity standards varied by exam type ranging from 7 (interventional radiology) to 31 (diagnostic) exams coded per hour. Diagnosis codes were assigned most frequently for diagnostic, ultrasound/nuclear, MRI/CT, and mammography exams, while diagnosis and procedural codes were assigned more frequently for interventional radiology exams. The need for education specifically focused on interventional radiology coding was identified along with other issues affecting the quality of radiology coding. Suggested solutions to challenges of radiology coding such as establishing a good working relationship with physicians, radiology, and charge description master (CDM) departments were suggested.

Key words: Radiology coding, reports, lists, reimbursement, coder, credentials, productivity standards, coding role, coding volume, continuing education

Introduction

A major job function within the health information management (HIM) profession is the assignment of medical diagnoses and procedures codes for administrative, financial, clinical, and research purposes. Systems for classifying diseases and procedures have been in existence since the late 19th century and have evolved over time to meet the data demands of the healthcare industry. Coding originally supported the need for clinical and research data; however, with the advent of Medicare and Medicaid the use of coded data has expanded to support the financial and reimbursement needs of the industry.1 Coding is now a major component of the billing and reimbursement processes of healthcare providers. It must be done in a timely and accurate manner for healthcare providers to receive payment for services rendered.2 The importance of coding cannot be overemphasized as the industry and federal government implement programs to control healthcare spending (e.g., prospective payment systems, present on admission [POA] reporting, recovery audit contractor (RAC) reviews) that rely heavily on quality coded data.3, 4 The challenge for healthcare providers is to ensure that all services rendered are identified and assigned codes according to correct coding guidelines. 

Radiology is one of these services. Radiology diagnostic and/or treatment procedures must be coded to meet federal regulations for Medicare and Medicaid reimbursement requirements. Past federal mandates requiring that interventional radiology and diagnostic angiography be coded using the Healthcare Common Procedural Coding System (HCPCS) (inclusive of Current Procedural Terminology [CPT]) followed by implementation of the Ambulatory Payment Classification (APC) system in 2000 have called attention to the need for accuracy and quality of coding but also to the need for individuals with expertise in radiology coding.5-7 The nuances of coding and increased federal regulations make radiology coding particularly challenging. In addition, anecdotal information suggests that hospitals and imaging centers may experience difficulty staying ahead of the curve in radiology coding.8 

Increased attention to timely claims reporting and reimbursement accuracy has pushed the importance of radiology coding to the forefront. This type of coding has the potential of becoming an important domain in HIM practice as the federal government pushes for healthcare reform through quality oversight and cost containment programs.9 Although HIM professionals have been responsible for diagnosis and procedure coding in a variety of healthcare venues, little is known regarding the role of HIM professionals in the domain of radiology coding. Thus, an exploratory study was undertaken to better understand the role and related practice issues of HIM professionals engaged in radiology coding. The study also sought to identify the challenges of radiology coding and the potential solutions to these challenges as implemented by HIM professionals.

Research Questions

The research questions used to guide this study were as follows:

  1. Who is responsible for radiology coding in selected healthcare facilities?
  2. What are practice issues as related to report types, what is coded, productivity standards, quality audits, volume of reports, and continuing education needs?
  3. What challenges do healthcare providers who engage in radiology coding face?
  4. What solutions have been implemented to address the challenges of radiology coding?

Methods

The research design for this study was a descriptive exploratory survey method that used a 15-item Web-based survey instrument (see Appendix A). The instrument was developed with input from experts in the field. It was also field tested and revised based on expert feedback. The survey consisted of six demographic questions (items 1–4, 12, and 13) and nine practice-related questions (items 5–11,14, and 15). Respondents were offered the opportunity to request a summary of the survey results and to be entered into a lottery for a gift as an incentive to complete the survey (items 16–18). Approval for the survey was sought and granted by The Ohio State University Institutional Review Board. An electronic survey application (SurveyMonkey) was used to distribute the survey to a sample of 828 individuals from the AHIMA Member Profile Database. The sample was composed of those individuals who identified themselves as director, manager, and/or supervisor; assistant or associate director, manager, and/or supervisor; coding manager; or billing manager. A follow-up reminder was sent approximately two weeks after the initial mailing to encourage completion of the survey.

Results

Survey Return Rate

Surveys were sent using an electronic survey method to 828 individuals. Twenty-nine individuals responded that they either were not the appropriate person to respond to the survey or were not working in the area. Thus, the adjusted number of surveys was 799, of which 278 were returned for data analysis purposes. This represents an adjusted survey return rate of 34.8 percent. Results of the survey are discussed below by research question. Frequencies and percentages may vary since many questions allowed the respondent to select more than one response.

Responsibility for Radiology Coding

Six demographic questions were asked to determine who was responsible for radiology coding in a given facility. The questions related to job title, professional credentials, employment setting, responsibility for coding, number of coders, and the coders’ credentials.

Job Title and Credentials of Respondents

Respondents were asked to identify their job title and what if any credentials they held (Table 1). Respondents could select more than one credential if appropriate. The majority of respondents (54.4 percent, n = 160) were department directors, managers, or supervisors and/or assistant or associate directors, managers, or supervisors. The second largest group of respondents were coding managers (37.6 percent, n = 103). The RHIT (Registered Health Information Technician) credential (53.6 percent, n = 148) was held by the majority of respondents, followed by the CCS (Certified Coding Specialist) (38.4 percent, n = 106) and RHIA (Registered Health Information Administrator) credentials (35.5 percent, n = 98). The remaining credential choices were held by limited numbers of respondents. In the “None” and “Other” categories, 11 of the 20 respondents identified academic degrees rather than credentials, and 4 identified the Physician Coding Specialist (PCS), Facility Coding Specialist (FCS), Advanced Coding Specialist-Obstetrics (ACS-OB), and Certified Health Physicist (CHP) credentials. In addition to the RHIT and RHIA credentials, the researcher was interested in the various credential combinations by job title that the respondents might hold. Table 2 provides an example of some of these combinations.

Employment Setting and Responsibility for Radiology Coding

Respondents were asked to indicate their employment setting and if their employment setting was responsible for facility radiology coding only, was responsible for physician practice radiology coding only, was responsible for both facility and physician practice coding, or had no responsibility for radiology coding (Table 3). Results revealed that the primary employment setting was the HIM department (82.4 percent, n = 224). Of respondents who chose “Other” (5.4 percent, n = 15), four identified themselves as working in an integrated hospital system and four listed “corporate” as their employment setting. This may mean that the coding function for radiology is centralized at a corporate level rather than in a specific HIM department. Two respondents identified their setting as consulting firms, and two indicated they worked for professional medical societies. The remaining employment sites were identified as occupational health, HMO, community health center, and skilled nursing facility (SNF). 

In regard to responsibility for radiology coding, 72.5 percent (n = 198) of the respondents indicated their department or unit was responsible for radiology coding, while 27.5 percent (n = 75) said their department or unit was not responsible for it. Respondents who were not responsible for radiology coding were directed to the end of the survey and were excused from completing the remainder of the survey. Of the 198 who responded that their employment setting was responsible for radiology coding, 63.7 percent (n = 174) indicated they did facility radiology coding. Only two respondents indicated they did physician practice radiology coding, while 8.1 percent (n = 22) indicated they did both facility and physician practice radiology coding.

Coders Dedicated to Radiology Coding

Respondents were asked to indicate how many coders were dedicated to radiology coding in their employment setting. Of the 189 who responded, 15 indicated that they did not know how many coders were dedicated to radiology coding and 11 commented their coders were cross-trained to code a variety of reports and were not dedicated specifically to radiology coding. The remaining 163 respondents reported that a total of 480 individuals were dedicated to radiology coding (Table 4). This number translates to an average of 3.4 full-time equivalents (FTEs) per employment setting with a range of 0.1 to 97 FTE coders per site.

FTE Coders and Credentials

The last demographic question asked respondents to indicate the number of FTEs responsible for radiology coding and to identify their credentials. Respondents included coders who were responsible for radiology coding as well as other forms of coding. Respondents identified a total of 550.75 FTE coders with the top three credentials reported as RHIT, CCS, and CPC (Certified Professional Coder). Of the 171 respondents who answered the question, 53.8 percent (n = 92) reported that 230.75 FTE coders held the RHIT credential, 39.2 percent (n = 67) reported that 124 FTE coders held the CCS credential, and 18.1 percent (n = 31) reported that 61.5 FTE coders held the CPC credential. Responses in the “Other” category identified four coders with the LPN credential, with the remaining comments related to unknown professional credentials or individuals not yet credentialed. Table 5 provides a summary of the responses along with the reported number of FTE coders per credential.

Practice Issues Related to Radiology Coding 

Seven questions were asked that addressed radiology coding practice issues related to whether coding is done from reports or lists, what is coded by exam type, productivity standards for reports and for lists, quality audits, and continuing education needs.

Reports and Lists

The first practice question asked respondents to indicate if coders coded from reports or lists. “Report” refers to an individual patient radiology report that is generated as a result of a radiology service rendered to a patient. Lists refer to lists of patients who received radiology treatment for a given time frame (by day, for example) that usually include dates of services, identifying information of patients receiving services, and diagnoses and/or procedures. Sixty-nine percent (n = 134) indicated coders coded mainly from individual radiology reports with a combination of reports and lists as the second choice (13.4 percent, n = 26) (Table 6). Of those who indicated “Other,” the majority identified orders (physician, admission, and/or requisition) as the source from which codes were assigned followed by coding from the superbill, charge ticket, and/or chargemaster.

Coding Role

The second practice question asked respondents to indicate what was coded based on the type of radiology exam (diagnostic, ultrasound/nuclear, MRI/CT, interventional radiology, and mammography) (Table 7). In regard to exam types of diagnostic (n = 115), ultrasound/nuclear (n = 114), MRI/CT (n = 112) and mammography (n = 110), results revealed that sites code diagnosis only most frequently followed by adding modifiers to CPT procedures. Approximately 25 percent of the respondents code both the diagnosis and CPT procedure from these exam types, with about 18 percent coding the diagnosis and chargemaster (CM) procedure code. However, in regard to interventional radiology, respondents indicated that both diagnoses and procedures (n = 104) were coded more frequently than diagnosis only. Sites also add CPT modifiers more frequently for interventional radiology exams than for other exam types. Sites code diagnoses and chargemaster (CM) codes for interventional radiology about the same as for the other exams. Altogether, a very small number of sites coded only CPT procedures.

Volume of Radiology Coding

The third practice question related to the volume of radiology coding done per month. Ninety-seven respondents provided monthly volume figures that ranged from 5 to 60,000 exams per month with an average volume of 4,245 per month. One eight-hospital system indicated that their volume was 95,000 collectively or 11,875 per facility per month. Four respondents identified that they only coded interventional radiology exams, which ranged from 40 to 500 per month. It is interesting to note that of the 198 possible respondents, only 97 provided information on volume, which raises the question as to why the others did not. Several commented that they did not keep this information, while others simply responded that they did not know.

Productivity Standards

The fourth and fifth practice-related questions addressed productivity standards for coding reports and lists. Respondents were asked to indicate if productivity standards were maintained for the various radiology reports and, if so, to enter the standard. Fifty-nine percent (n = 89) of the 151 individuals who responded to the question indicated they maintained productivity standards for the various reports versus 41 percent (n = 62) who indicated they did not maintain productivity standards. The data were summed and averaged to determine an hourly standard by exam type. In regard to “Other,” of the 25 responses, 18 indicated no standard was kept, while 7 offered a general productivity standard of 75 to 100 reports per day regardless of exam type. The same question was asked in regard to productivity standards for coders who coded radiology procedures from lists. Of the 87 responses, 31 percent (n = 27) indicated that productivity standards were maintained for radiology coding from lists. The majority of respondents (69 percent, n = 60), however, reported that they did not maintain standards. Table 8 provides a summary by percent and frequency for those who responded positively to the question along with the range and productivity standard per hour for the various exam types.

Quality Audits

As a follow-up to productivity standards, respondents were asked to indicate if separate radiology coding quality audits were performed by their employer. Anecdotal information revealed that quality standards fell between 95 and 98 percent. The majority of respondents (47.7 percent, n = 93) indicated that radiology coding audits were included in routine coding audits. Twenty-seven percent (n = 52) reported that separate radiology audits were performed, while 22 percent (n = 43) reported that audits were not conducted.

Continuing Education

Given the complexity of radiology coding and continuing regulatory changes, the need for continuing education is important; thus, the respondents were asked how satisfied they were with opportunities for continuing education and/or training related to radiology coding. They were also given the opportunity to comment on the need for education in this area of practice. Overall, the respondents appeared to be satisfied to very satisfied with educational opportunities regarding radiology coding (Table 9). Twenty-six respondents offered comments that focused on the need for educational programming in the area of interventional radiology. It is interesting to note that nearly 14 percent (n = 27) of the respondents were not aware of continuing education programs for radiology coding.

Challenges to Radiology Coding

Respondents were asked to identify what if any challenges their employment setting faced in regard to radiology coding. Respondents were given nine challenges to select from in addition to space for comments in the “Other” category (Table 10). Eighty-four percent (n = 158) of those who responded to the question indicated that they faced one or more challenges in their employment setting while 16.4 percent (n = 31) indicated no challenges. The top five challenges were lack of physician documentation (42.3 percent, n = 80), keeping up with payer rules and edits (38.6 percent, n = 73), lack of continuing education opportunities in radiology coding (28 percent, n = 53), access to expert coders (24.9 percent, n = 47), and high volume of work (21.7 percent, n = 41).

Solutions to Challenges

The last question was open-ended and provided the respondents with the opportunity to comment on whether their employment setting had successfully addressed any of the above challenges. Fifty-four respondents offered comments regarding solutions to their radiology coding challenges. Comments were reviewed and grouped by solution theme. The most prevalent solution noted was to offer staff education and training programs. The second most prevalent response focused on the importance of establishing working relationships with physicians, the radiology department, and/or the chargemaster management department. The third solution was the use of consultants to fulfill coding and/or training needs. Fourth, respondents sought to hire individuals with credentials and/or specializations in radiology coding. The last solution theme centered on implementation and use of technology applications to confirm the medical necessity of procedures.

Discussion

An exploratory study of radiology coding in HIM practice was conducted to better understand the HIM role in radiology coding and to identify issues and challenges related to this specialty area of coding. An electronic survey was sent to 828 AHIMA members who had identified themselves as department director, manager, or supervisor; assistant or associate director, manager, or supervisor; coding manager or billing manger. Two hundred seventy-eight surveys were returned for a 34.8 percent return rate. The majority of respondents indicated that their employment setting was responsible for facility and/or physician practice radiology coding and that they mainly coded from radiology reports. Sites reported on average that 3.4 coders were engaged in some form of radiology coding. The most common professional credentials held by coders were RHIT, CCS, and/or CPC. The average number of reports coded per month was 4,245 with a range of 5 to 60,000 reports per month. As expected, the more coders at a site, the more radiology reports were coded.

Coders tended to code diagnoses only followed by adding CPT modifiers for diagnostic (n = 115), ultrasound/nuclear (n = 114), MRI/CT (n = 112), and mammography (n = 110) exams. Approximately 25 percent of the respondents coded both the diagnosis and CPT procedure from these exam types with about 18 percent coding the diagnosis and chargemaster procedure code. However, for interventional radiology, both diagnoses and procedures (n = 104) were coded more frequently than diagnosis only. Sites also added CPT modifiers more frequently for interventional radiology exams than for the other exam types. Sites coded diagnoses and CM codes for interventional radiology with the same frequency as the other exams. 

Productivity standards for radiology coding varied by exam type and ranged from 7 per hour for interventional radiology exams to 31 per hour for diagnostic exams. The productivity standard for all reports was 24 per hour. It is not surprising to find a difference in productivity standards based on exam type since interventional radiology may encompass more complex diagnoses and procedures. Very few employment settings appear to code from lists. However, for those respondents who indicated that their site coded from lists, the productivity standards were not much different than coding from reports except for interventional coding, where the average productivity standard for coding by reports was 7 versus 21 from lists. Because few respondents indicated that they code from lists, the standards are questionable. However, the quality of radiology coding is important given issues related to claims reporting and reimbursement accuracy. Overall, 73 percent of the respondents indicated that quality audits were performed on radiology coding. 

In regard to continuing education needs, the majority of respondents reported that they were satisfied to very satisfied with the continuing education and/or training opportunities available to them. However, comments offered by respondents also indicated a need for education specifically focused on interventional radiology coding. This result should be viewed with caution since the respondents to the survey do not reflect general coders but individuals with some form of managerial responsibility for coding in their employment setting. Thus, nonmanagerial coders engaged in radiology coding should be surveyed to determine if these individuals have the same satisfaction level with continuing education opportunities as found in this study. 

As the federal government’s cost-control oversight efforts continue to increase, it is important to understand the challenges HIM professionals face in the arena of radiology coding. Eighty-four percent (n = 158) of the respondents reported experiencing one or more challenges related to radiology coding. Lack of physician documentation was the top challenge (42.3 percent, n = 80), followed by keeping up with payer rules and edits (38.6 percent, n = 73); these two challenges are common to the overall responsibility of coding as documented in the literature.10 The third highest ranked challenge was lack of continuing education opportunities for radiology coding (28 percent, n = 53). This finding suggests that while respondents may be satisfied with previous continuing education and/or training related to radiology coding, there is more need for continuing education and training opportunities in this area. 

Another important challenge was access to expert radiology coders (24.9 percent, n = 47). The need for coders in general is well documented, so it is not surprising that study respondents also identified the need for coders in radiology.11 Many respondents indicated that their coders were responsible for a variety of coding specializations as well as radiology coding. However, as HIM departments and professionals assume more responsibility for radiology coding, the need for experts will continue to increase. The need is also evidenced by an increase in the availability of certification options for radiology coders offered by a variety of professional organizations. At the time of this writing, at least four organizations offer specific credentials related to radiology coding that were nonexistent a decade ago (Figure 1). In addition to these organizations, four other organizations support individuals who engage in radiology coding through a variety of educational programming opportunities.

To address the challenges discussed above, numerous solutions have been proposed and implemented. Offering education and training through in-service training or seminars and the use of consultants for training were reported as helpful solutions and are also suggested by Heubusch.12 Hiring individuals with credentials and specialization in radiology coding appears to have helped and perhaps verifies why we are seeing growth in organizations that offer such credentials. For some, establishing a good working relationship with physicians, radiology, and CDM departments has been helpful. In addition, the use of software applications to confirm the medical necessity of exams has helped.

Conclusion

In conclusion, radiology coding is a specialty area of coding that has grown in importance with increased federal regulation. It appears that HIM professionals play a role in radiology coding whether in the actual coding of exams and procedures or in managing the function of radiology coding in general. The responsibility for radiology coding will continue to grow along with the interest in hiring individuals with a specialty certification in this area of practice. Although a number of organizations offer certification in radiology coding, it may behoove the Commission on Certification for Health Informatics and Information Management of AHIMA to implement a specialty certification in radiology coding for three reasons:

  1. to complement the credentials (RHIA, RHIT, CCA, CCS, CCS-P) of individuals currently engaged in radiology coding;
  2. to offer an option for those engaged in radiology coding who are not yet credentialed; and
  3. to further professionalize the practice of radiology coding since credentialing demonstrates that an individual has met established standards of practice. 

In addition, consideration should be given to offering continuing education opportunities to coders in this specialty area, particularly those who are responsible for interventional radiology coding. Since this study surveyed only members of AHIMA, it would also be of interest to survey radiology coders from other membership or certification organizations to better understand the similarities and/or differences in practice issues and challenges facing all coders involved in radiology coding. A limitation of the study is that it used self-reported data; however, by expanding the study to other groups we can develop a more global understanding of radiology coding in general. Last, the actual processes used by healthcare providers to code radiology diagnoses and procedures should be examined to determine if work processes influence the accuracy and quality of radiology coding.

 

Melanie Brodnik, PhD, RHIA, is a director and associate professor of health information management systems at the Ohio State University in Columbus, OH.

 

Acknowledgments

This project was funded by the AHIMA Foundation through a generous contribution from Health Record Services Corporation. Special acknowledgement is given to Wendy Coplan Gould, RHIA, president of Health Record Services Corporation. We would also like to acknowledge the assistance of Beth Friedman, RHIT, of Friedman Marketing Group.

Notes

 

1. Greene, M. J., and M. M. Foley. “Clinical Classification and Terminologies.” In K. M. LaTour and S. E. Maki (Editors), Health Information Management: Concepts, Principles and Practice. Chicago, IL: AHIMA, 2009, 347–68.
2. Casto, A. B., and E. Layman. Principles of Healthcare Reimbursement. Chicago, IL: AHIMA, 2009.
3. Garrett, Gail. “Present on Admission: Where We Are Now.” Journal of AHIMA 80, no. 7 (2009): 22–26.
4. Johnson, Kathy M., Allison Bloom, Denise Morris, and Rod Madamba. “RAC Ready: How to Prepare for the Recovery Audit Contractor Program.” Journal of AHIMA 80, no. 2 (2009): 28–31.
5. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare Program Prospective Payment System for Hospital Outpatient Services; Final Rule. Federal Register vol. 65, no. 68, April 7, 2000. 42 CFR Parts 409, 410, 411, 412, 413, 419, 424, 489, 498, and 1003.
6. Rangachari, P. “Coding for Quality Management: The Relationship between Hospital Structural Characteristics and Coding Accuracy from the Perspective of Quality Management.” Perspectives in Health Information Management 4, no. 3 (April 2007). Available at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036020.html.
7. O’Malley, K., K. Cook, M. Price, K. Raiford-Wildes, J. Hurdle, and C. Ashton. “Measuring Diagnosis: ICD Code Accuracy.” Health Services Research 40, no. 5, part 2 (2005): 1620–39.
8. Coplan, W. News Release: Health Record Services Partners with AHIMA for Radiology Coding Research. April 29, 2008.
9. Rode, Dan. “Summer Healthcare Forecast: Reform, ARRA Make for an Unsettled Season in DC.” Journal of AHIMA 80, no. 7 (2009): 19–20.
10. O’Malley, K., K. Cook, M. Price, K. Raiford-Wildes, J. Hurdle, and C. Ashton. “Measuring Diagnosis: ICD Code Accuracy.” “Measuring Diagnosis: ICD Code Accuracy.”
11. Dover, Kayce. “Keys to Finding and Retaining HIM Talent.” 2008 AHIMA Convention Proceedings, October 2008.
12. Heubusch, K. “Coding’s Biggest Challenges Today.” Journal of AHIMA 79, no. 7 (2008): 25–28.

 

Article citation: Perspectives in Health Information Management 6, Fall 2009

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