Purpose or Case Report: Coding and billing processes are complex, costly, and generally poorly understood by radiologists and other physicians. Despite the direct implications of radiology documentation on reimbursement, residents, fellows, and practicing radiologists receive little or no training in coding-related issues. It is thus important to understand the fundamentals of documentation, coding, billing, and reimbursement as they apply to the practice of pediatric radiology.
Methods & Materials: This presentation: (1) provides an overview of the unique payer structure within pediatric radiology including state-based CHIP programs, (2) discusses the essential processes by which radiologists request and receive reimbursement, (3) details the mechanisms of coding diagnoses using International Classification of Disease (ICD-10-CM) codes and imaging services using Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, and (4) explores reimbursement and coding-related issues specific to the practice of pediatric radiology.
Results: Radiologists can improve coding accuracy and enhance legitimate revenue through careful documentation of clinical necessity and detailed description of the services provided with an understanding of the components required for correct billing. Pediatric radiology presents unique challenges to reimbursement, including a unique study type distribution that favors lower cost studies and averts higher-valued cross-sectional imaging. In addition, no additional reimbursement is typically provided for the added complexity of interventional procedures and imaging studies in children. As such, many commonly-performed pediatric radiology services are undervalued.
Conclusions: Appropriate documentation, informed by knowledge of coding, billing, and reimbursement fundamentals, facilitates correct coding to ensure appropriate reimbursement for clinically-relevant services provided by pediatric radiologists. Understanding the payer and reimbursement environment specific to pediatric radiology can enhance advocacy efforts for pediatric radiology practices to provide economically sustainable access to high-quality care for children.