Exploratory Study of Radiology Coding in Health Information Management Practice

Abstract

An exploratory study was undertaken to determine the role and practice issues of radiology coding in health information management (HIM) practice. The study sought to identify the challenges of radiology coding and the solutions implemented to address these challenges. A sSelf-reporting survey was sent to AHIMA members identified as directors, managers, supervisors of HIM departments and/or coding. Two hundred seventy-eight surveys[v1] were returned for a response rate of 34.8%. Respondents answered questions related to job title, professional credential, employment setting, responsibility for coding, number of coders and coder credentials. In addition, respondents were asked whether coding was done from reports or lists, and what was coded from these documents. Productivity standards were identified along with continuing education needs, coding issues and solutions to these issues.

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 coding of medical diagnoses and procedures for administrative, financial, clinical and research purposes. Healthcare providers who provide radiology diagnostic and/or treatment procedures must code all such exams and/or procedures to meet federal regulations for Medicare and Medicaid reimbursement requirements.Past federal mandates requiring that interventional radiology and diagnostic angiography be coded using HCPCS/CPT followed by implementation of the APC payment process in 20001 have increased attention on the need for accuracy and quality of coding2 but also the need for individuals with expertise in radiology coding. 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.3

Increased attention to timely claims reporting and reimbursement accuracy has pushed the importance of radiology coding to the forefront. It has the potential of becoming an important domain in HIM practice as the federal government expands programs of healthcare cost containment and quality oversight.Health information management professionals are responsible for coding in a variety of healthcare venues, however, little is known regarding the role of HIM professionals in the domain of radiology coding. Thus, an exploratory study was undertaken to better understand this roleand related practice issues, if any, of HIM professionals engaged in radiology coding. The study also sought to identifythe challengesof 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:

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 need?

3)What challenges do healthcare providers face who engage in radiology coding?

4)What solutions have been implemented to address the challenges of radiology coding?

Methods

The research design for this exploratory study was a descriptive survey[v2] method. A 15item questionnaire was developed with input from experts in the field. The instrument was field tested and revised based on expert feedback (See Appendix A). The survey consisted of 6 demographic questions (items1-4,12,13) and 9 practice related questions (items 5-11,14-15). Respondents were offered an opportunity to request a summary of the survey results and to enter 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 electronically toa sample of828 individuals from the AHIMA Member Profile Database 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 2 weeks after the initial mailing to encourage return of the survey[v3].

Results

Survey Return Rate

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

Research Question 1: Who is responsible for radiology coding in selected healthcare facilities?

Six demographic questions were asked related to job title, professional credential, employment setting, responsibility for coding, number of coders and their credentials.

Job Title and Credentials of Respondents

Respondents were asked to identify their job title and what if any credentials they held (Table 1). The majority of respondents (58.4%, n=160) were department directors; managers,supervisors and/or assistant or associate directors. The second largest group of respondents werecoding managers (37.6%, n=103). The RHIT credential (53.6%, n=148) was held by the majority of respondents followed by the CCS (38.4%, n=106) and RHIA credentials (35.5%, n=98). Keep in mind[v4] respondents could select more than one credential. The remaining credential choices were limited in number. In the “None and Other” category 11 or the 20 respondents identified academic degrees rather than credentials and four the identified the credentials of: Physician Coding Specialist (PCS), Facility Coding Specialist (FCS), Advanced Coding Specialist-Obstetrics (ACS-OB) and Certified Health Physicist (CHP) respectively.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 3 provides an example of some of these combinations.

Employment Setting andResponsibility for Radiology Coding

Respondentswere asked to indicate their employment setting and if their employment setting was responsible for facility radiology coding, physician practice radiology coding, both facility and physician practice coding or had no responsibility for radiology coding (Table 3). Results revealed that the primary employment settingwas the HIM department,82.4% (n= 224). For those individuals who chose “Other” (5.4%, n=15), 4 identified themselves as working in an integrated hospital systemand 4 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 2 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, 73% (n=198) of the respondents indicated their department or unit was responsible for radiology coding while 27.5% (n=75) said they were not responsible. If the respondent indicated they were not responsible for radiology coding they 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% (n=174) indicated they did “facility” radiology coding. Only 2 respondents indicated they did “physician practice” radiology coding while 8.1% (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 (Table 4). The remaining 163 respondents reported that a total of 480 individuals were dedicated to radiology coding. This number translates to an average of 3.4 FTEsper employment settingwith 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 identified a total of 550.75 [v5]coders with the top three credentials reported as RHIT, CCS and CPC.Please note respondents included coders who were responsible for coding radiology as well as other forms of coding. Of the 171 respondents who answered the question, 53.8% (n=92) reported that 230.75 coders held the RHIT credential, 39.2% (n=67) reported that 124 coders held the CCS credential and 18.1% (n=31) reported that 61.5 coders held the CPC credential. Table 5 provides a summary of the response percent and count of respondents along with their reported number of coders per credentials. Responses in the “Other” category identified 4 coders with the LPN credential with the remaining comments related to “not knowing the professional credentials”, or individuals “not credentialed as yet”.

Research Question 2: What are practice issues as related to report types, what is coded, productivity standards, quality audits, volume of reports and continuing education need?

Seven questions were asked that addressedradiology 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. Reports refer to anindividual 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 timeframe (by day for example) that usually include dates of services, identifying information of patients receiving service, 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%, 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 respondentsto indicate what was coded based on 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 frequentlyfollowed by adding modifiers to CPT procedures. Approximately 25% of the respondents code both the diagnosis and CPT procedure from these exam types with about 18% coding the diagnosis and charge-master (CM) procedure code. However, in regard to interventional radiology, respondents indicated that both “diagnoses and procedures”(n=104) were codedmore frequently than “diagnosis only”. Sites also add CPT modifiers more frequently for interventional radiology exams than other exam types. Sites code diagnoses and chargemaster (CM) codes for interventional radiology about the same as the other exams. Altogether, a very small number of sites codedonly 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 which ranged from 5 to 60,000exams per month with an average volume of 4,245 per month. One 8 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 questions as to why the others did not respond to the question. Several commented that they did not keep this information while others simply responded that they didn’t know.

Productivity Standards

The fourth and fifth practice related questionsaddressed 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% (n=62) who indicated they did notmaintain productivity standards. Data was summed and averaged to determine an hourly standard by exam type. In regard to “Other”, of the 25 responses 18 responded with “N” which indicated no standard was kept, while 7 offereda general productivity standard of 75 to 100 reportsper day regardless of examtype. The same question was asked in regard to productivity standards for coders who coded radiology procedures from list. Of the 87responses, 31% (n=27) indicated that productivity standards were maintained for radiology coding from lists. The majority of respondents, (69%, 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 employment setting. The majority of respondents (47.7%, 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% (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 whichfocused on the need for educational programming in the area of interventional radiology. It is interesting to note that at least 14% (n=27) of the respondents were not aware of continuing education programs for radiology coding.

Research Question 3: What challenges do healthcare providers face who engage in radiology coding?

Respondents were asked to identify what if any challenges their employment setting faced in regard to radiology coding. Respondents were given 9 challengesto select from in addition to space for comment 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% (n=31) indicated no challenges. The top five challenges were: “Lack of physician documentation” (42.3%, n=80), “Keeping up with payer rules and edits” (36%, n=73); “Lack of continuing education opportunities in radiology coding” (28%, n=53); “Access to expert coders” (24.9%, n=50) and “High volume of work” (21.7%, n=43).

Research Question 4: What solutions have been implemented to address the challenges of radiology coding?

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 challenges of radiology coding. Comments were reviewed and grouped by solution theme. The most prevalent solution noted was the offering of staff education and training programs. Second most prevalent response focused on the importance of establishing working relationships with physicians, radiology department and/or 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/associate director, manager, or supervisor; coding manager or billing manger. Two hundred seventy-eight surveys were returned for a 34.8% 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 larger volume of radiology reports coded.

Coders tend 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% of the respondents code both the diagnosis and CPT procedure from these exam types with about 18% coding the diagnosis and charge-master (CM) procedure code. However, for interventional radiology, 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 the other exam types. Sites code 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 7for interventional radiology exams to 31for diagnostic exams coded per hour. 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 that indicated that their site coded from lists the productivity standards were not much different than coding from reports except for interventional coding were the average productivity standard for coding by reports was 7 versus 21 from lists. So few respondents indicated that they code from lists, thus the standards are questionable. However, the quality of radiology coding is important given issues related to claims reporting and reimbursement accuracy. Overall, 73% of the respondents indicated that quality audits were performed on radiology coding.