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

Pediatr Radiol. 2018 Jul;48(7):904-914. doi: 10.1007/s00247-018-4104-1. Epub 2018 Mar 19.

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.

Keywords: Billing; Coding; Current Procedural Terminology; Health insurance; Pediatric radiology; Reimbursement.

Publication types

  • Review

MeSH terms

  • Clinical Coding*
  • Current Procedural Terminology
  • Diagnostic Imaging / economics*
  • Documentation / methods
  • Forms and Records Control
  • Humans
  • Insurance Claim Reporting / economics
  • Insurance, Health, Reimbursement / economics*
  • International Classification of Diseases
  • Pediatrics / economics*
  • Radiologists*
  • Reimbursement Mechanisms / economics
  • United States