This document provides guidelines for selecting accurate diagnosis codes for radiology billing. It states that the test order from the referring physician and the radiology report must both be reviewed to determine the primary diagnosis code. The test order establishes medical necessity but the radiology report's final impression informs the specific diagnosis code. Following official coding guidelines is important for ensuring insurance reimbursement. Contacting the provided company can help with medical billing and coding for radiology services.

1. Diagnosis Coding Guidelines For Radiology Billing

2. Call us at: 302-261-9187
Email us at: richard.smith@medisysdata.com
Diagnosis Coding Guidelines For Radiology Billing
Submitting a clean claim and bringing accurate reimbursement for radiology is a challenging task requiring billing and
coding expertise. Although many claims are being paid when initially submitted, post-payment reviews by insurance
carriers might result in returning the insurance reimbursements. All this can be avoided with proper documentation
supporting medical necessity. With radiology services coming under intense scrutiny for medical necessity, it is more
important than ever to ensure documentation supporting medical necessity. This includes ensuring that diagnosis
coding is done in accordance with the official coding guidelines and the Center for Medicare & Medicare Services (CMS)
policy. Following diagnosis coding guidelines will support medical necessity ensuring insurance reimbursements while
billing for radiology services.
Diagnostic Test Order
An encounter for radiology services begins with a test order from the referring (ordering physician) which is then taken
to an imaging center, hospital, or another provider of diagnostic imaging services. A complete and accurate test order is
crucial to coding compliance because payment for services by Medicare is made only for those services that are
reasonable and necessary. Furthermore, CMS charges the referring physician with the responsibility of documenting
medical necessity as part of the Medicare Conditions of Participation (42 CFR 410.32).
• The Balanced Budget Act of 1997 reiterates the above requirement in Section 4317(b) where it states that the
ordering physician must provide signs/symptoms or a reason for performing the test at the time it is ordered. If the
referring physician indicates a ‘rule out’, he/she must also include signs/symptoms prompting the exam for ruling out
that condition.

3. Call us at: 302-261-9187
Email us at: richard.smith@medisysdata.com
Diagnosis Coding Guidelines For Radiology Billing
• In the event this information is missing, the ordering physician should be contacted for this information before
proceeding with the exam.
• Since medical necessity is determined by those signs/symptoms provided by the ordering physician, it is vital to have
this information at the time of final coding even when the radiology report identifies an abnormal finding or
condition. This information is key in helping to determine whether or not a finding is incidental or related to the
presenting signs/symptoms.
• Furthermore, a test ordered to ‘rule out’ a specific condition is considered a screening exam in the eyes of Medicare
and would need to be coded as such in the absence of documented signs/symptoms, with a screening code assigned
as the primary diagnosis and any findings assigned as additional diagnoses.
Choosing the Primary Diagnosis
As per ICD-10-CM official guidelines, for patients receiving diagnostic services only during an encounter/visit, sequence
first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly
responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic
conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the
absence of any signs, symptoms, or associated diagnosis, assign Z01.89.

4. Call us at: 302-261-9187
Email us at: richard.smith@medisysdata.com
Diagnosis Coding Guidelines For Radiology Billing
If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is
appropriate to assign both the Z code and the code describing the reason for the non-routine test. For outpatient
encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of
coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and
symptoms as additional diagnoses.
Radiology Report
While the test order may determine medical necessity and initially drive the encounter, a review of the final radiology
report holds the key to determining the correct diagnosis codes for an encounter. Radiology reports should contain four
main sections: clinical indications; technique; summary of findings; and impression and final interpretation. The clinical
indications listed on the report should be those signs or symptoms provided by the referring physician that prompted
the ordering of the test. The radiologist’s final interpretation, the impression, may list multiple conditions and is the final
piece of the puzzle in choosing a primary diagnosis code. Additionally, a careful review of the clinical indications will help
determine whether or not certain conditions mentioned in the findings section, or in the impression, are clinically
significant or simply incidental findings.

5. Call us at: 302-261-9187
Email us at: richard.smith@medisysdata.com
Diagnosis Coding Guidelines For Radiology Billing
Documentation for Diagnosis Code
At first glance it may appear that diagnosis coding for diagnostic radiology exams is straightforward, it actually can be
quite challenging. In many cases, the documentation that must be reviewed prior to assigning a diagnosis code may be
unavailable, unclear, or contradictory. There are two key documents for review. Although each is a viable source
document for selecting a diagnosis code for the encounter, utilizing only one of these two documents to select
procedure and diagnosis codes can result in unnecessary coding compliance risks for any provider of services.
• Test order with accompanying signs/symptoms
• Radiology report containing the final written interpretation
Accurate selection of diagnosis codes and following coding guidelines will ensure steady insurance reimbursements in
radiology billing. If you need any assistance in medical billing and coding for radiology billing, we can help. Medisys Data
Solutions Inc. is a leading medical billing company that is well versed with billing policies and coding guidelines for
radiology billing. To discuss your radiology specific billing requirements, contact us at info@medisysdata.com/ 302-261-
9187

6. Address
8 The Green STE A, Dover,
Delaware 19901. USA.
Phone Number
302-261-9187
E-mail Address
info@medisysdata.com
THANK YOU
If you have any questions or queries about medical billing services, our member of staff
will always be happy to help. Feel free to contact us.