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Understanding the New MRI Safety Codes for 2025

Coding

Understanding the New MRI Safety Codes for 2025

Magnetic Resonance (MR) safety is a critical concern due to the powerful magnetic fields and radiofrequency energy used in Magnetic Resonance Imaging (MRI) scans. The MR environment has the potential to pose significant risks to patients with implanted medical devices or foreign bodies. These objects may heat up, move, or malfunction, potentially causing harm. Prior to 2025, there was no specific way to report the extra effort involved in assessing and mitigating these risks before an MR exam or procedure. Now, providers can be reimbursed for the essential tasks required to safeguard these patients, including implant or foreign body evaluation, implant positioning or immobilization, safety consultation, and preparation of electronic devices. This change acknowledges the importance of MR safety protocols and supports the necessary steps to protect patients while maintaining imaging quality. 

 

New MR Safety Codes for 2025

 

The 2025 CPT code set includes six new codes representing MR safety services. The new codes portray safety services that are beyond the standard safety screening performed for all patients receiving an MR examination, which are not reported separately. In addition, not all patients with a medical device or foreign body will need the safety services represented by the new code set. For example, if a patient has a medical device known to be MR-safe and requires no modifications to the exam, the safety services represented by the new code set are not needed.

 

Patients requiring services represented by the new code set include:

  • Those with a medical device or foreign body that lacks MR conditional labeling for which additional time and research are needed to determine the safety of the device.
  • Those whose devices are determined to be contraindicated for the MR examination or require additional safety precautions and/or modifications to the MR examination.

 

As stated in the 2025 CPT Manual:

 

"Implants may have FDA-approved labeling specifying conditions under which an MR examination could be safely performed. These conditions can specify the type of MR equipment to use, preparation of the implant before the MR procedure, anatomical regions that should be excluded from the MR examination, limitations on MR scan time and energy deposition, and/or implant components that may contraindicate MR examination."

 

If a device that lacks conditional labeling is researched and determined to be "MR Safe," it poses no safety hazard in the MR environment and requires no modifications to the MR examination. Those safety findings are documented in the patient's medical record. If the patient is later seen for a subsequent MR examination, repeat safety services (clinical staff research) are not required or reported, since the previous safety service findings are accessible in the medical record. A device determined to be "MR Conditional" indicates that it is safe only under certain MR conditions, and the MR examination may need to be modified to accommodate those conditions. If a device is determined to be "MR Unsafe," it poses an unacceptable risk in the MR environment and should never be brought near an MR machine.


Also important to understanding the new MR safety services code set is the concept of "technical component" and "professional component," as well as the difference between physicians and clinical staff. The "technical component" of a service represents any work completed by clinical staff (e.g., MR safety officer, MR technologist, medical physicist, nurse, etc.), while the "professional component" represents the work performed by the physician or other qualified healthcare professional (QHP).

 

Date of Service (DOS)

 

The first three codes in the series, CPT codes 76014–76016, represent MR safety services provided prior to the date of service (DOS) of the MR examination; however, exceptions can be made for emergent situations. The final three codes, 76017–76019, represent MR safety services provided on the same DOS as the MR examination.

 

MR Examination Not Performed

 

There is one MR safety code (76017), which represents MR safety services that are provided in real-time as the MR examination is being performed. Apart from CPT 76017, all other MR safety services should still be reported if the MR examination is not performed. The MR safety codes are standalone services that are separate and distinct from the MR examination.

 

Reporting Multiple MR Safety Services

 

There may be instances where more than one MR safety service is needed to ensure patient safety. These codes may each be reported independently for the same MR examination. Codes 76017–76019 are modifier 51 exempt, which means there is no multiple service payment reduction when reporting all three codes for the same MR examination.

 

CPT Code Series 76014–76019

 

Following is a summary of the new codes, including recommended documentation requirements as stated in the CPT® and RBRVS 2025 Annual Symposium and clinical example summaries from CPT® Changes: An Insider's View 2025. See Table 1.

 


Table 1

Safety Services on Date Prior to MR Exam

CPT
Code

Description

CY 2025 Medicare Work RVUs

76014

 

MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (e.g., surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; initial 15 minutes.

Technical Component Only

 

76015

 

Each additional 30 minutes (List separately in addition to code for primary procedure).

Technical Component Only

76016

MR safety determination by a physician or other qualified healthcare professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examination, analysis of risk vs. clinical benefit of performing MR examination, and determination of MR equipment, accessory equipment, and expertise required to perform examination, with written report.

0.60

 

 


 

Analysis and Documentation by Clinical Staff (CPT 76014 and 76015)

 

The first two codes in the new code set, CPT 76014 and 76015, represent the technical component for any preparatory research performed by clinical staff. These services are performed on a date prior to the MR exam, have no physician involvement or work, and do not require a modifier. After performing the necessary research for the medical device in question, the clinical staff needs to document their findings in the medical record for review by the physician and identify whether the device is MR Safe, MR Conditional, or MR Unsafe and any applicable contraindications for the MR exam. 


These two codes are time-based; clinical staff should include the total time spent on research in their documentation. As time-based codes, staff must meet the midpoint threshold to support billing. For example, CPT 76014 is billed for the initial 15 minutes spent performing the analysis; if the clinical staff member spends 8 minutes, they have exceeded the midpoint threshold of time and can bill the service. If the clinical staff only spends 7 minutes, it is not billable as they did not cross the midpoint threshold time requirement. Add-on CPT code 76015 represents each additional 30 minutes of research; therefore, a minimum of 16 minutes of research must be performed in order to report the service in addition to CPT 76014. CPT 76015 can be reported a maximum of three times per encounter.


The AMA provides the following clinical example:

 

"Clinical Example Summary: An MRI of the lumbar spine is ordered for a patient with a neurostimulator. The medical record does not include model information for the implanted leads. Certain lead models have anatomical exclusion zones over the implant. MR conditions for the implant are dependent on the lead model; therefore, clinical staff must use appropriate sources, such as a patient screening form, surgical reports, or review of prior imaging and various databases, in order to determine MR conditional status of the implanted leads. This information is documented in the patient's medical record to be accessed by the radiologist and/or MRSO. Documentation should indicate the leads as either MR safe, MR conditional, or MR unsafe."

 

Analysis and Documentation by Physician or QHP (CPT 76016)

 

CPT 76016 represents work on a date prior to the MR exam but is performed by the physician or other qualified healthcare professional (QHP). In emergent situations, this may be performed on the day of the MR exam. The physician or QHP must document the findings and analysis in a formal written report. 


This code is intended for situations where an implant and/or foreign body lacks MR conditional labeling, is contraindicated for MR, or may result in a limited MR examination based upon the performance of an MR safety determination by a physician or other QHP responsible for the safe performance of the MR procedure. If the device or implant is known to be MR safe or if the MR conditional labeling is clear or not relevant, a risk-benefit analysis is not needed as they do not present a limitation to the performance of the MR exam.


The physician should assess the proximity of the implanted device/foreign body to sensitive tissues and evaluate the clinical risk to the patient if device malfunction, thermal injury, or displacement forces are induced by the MR exam procedure. The MR exam parameters are reviewed for conformance with implanted device safety instructions, and, if not, decide whether informed consent should be obtained prior to the MR exam.  Alternative diagnostic tests are considered for appropriateness and relative risk.


The report should address the issues related to the implanted device and the MR exam. If the device is determined to be "MR Conditional," a risk-benefit analysis by a physician or other QHP responsible for the safe performance of the MR exam should be included. If it is determined that the MR exam can be conducted, additional documentation should address what needs to be scanned, the specific sequences, if the risks outweigh the benefits, and if there is any special MR equipment or expertise needed to carry out the exam.


The AMA provides the following clinical example:

 

"Clinical Example Summary: A pacemaker lacks MR conditional labeling and programming modes. A physician or other QHP performs a risk-benefit analysis, including review of MR safety parameters for conformance with implanted-device safety instructions. If MR safety parameters do not conform with the implanted-device safety instructions, the physician or other QHP will consider alternative diagnostic tests for appropriateness and risk, and make recommendations for alternative tests, procedures, or MR requirements."

 

In the event the MR exam is cancelled based on the findings of the MR safety review and analysis, the services related to the analysis can be billed. See Table 2.

 

Table 2

Safety Services on Date of the MR Exam

CPT Code

Description

CY 2025 Medicare Work RVUs

76017

MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified healthcare professional to prioritize and select views and imaging sequences, to tailor MR acquisition specific to restrictive requirements or artifacts associated with MR conditional implants or to mitigate risk of non-conditional implants or foreign bodies, with written report.

0.76

76018

MR safety implant electronics preparation under supervision of physician or other qualified healthcare professional, including MR-specific programming of pulse generator and/or transmitter to verify device integrity, protection of device internal circuitry from MR electromagnetic fields, and protection of patient from risks of unintended stimulation or heating while in the MR room, with written report.

0.75

76019

MR safety implant positioning and/or immobilization under supervision of physician or other qualified healthcare professional, including application of physical protections to secure implanted medical device from MR-induced translational or vibrational forces, magnetically induced functional changes, and/or prevention of radiofrequency burns from inadvertent tissue contact while in the MR room, with written report.

0.60

 


 

Analysis and Documentation by Physician or QHP (CPT 76017–76019)

 

Some devices may require MR safety exam customization in real-time as the MR examination is performed. The staff performing this work would likely be the medical physicist or MR safety expert (under supervision of the physician or other QHP for CPT 76017 or qualified clinical staff for CPT 76018 and 76019). Physician supervision and physician work should be evident in the documentation pertaining to each of these codes.  


The reports for CPT 76017 and 76018 should address any MR safety exam customization or changes made in real-time on the date of the MR exam. Report documentation on how the examination was customized and modified for specific patient circumstances should include a review of exam indications, analysis, and any adjustment of the MR scanning protocols based on specific patient parameters and imaging requirements, and monitoring of the performance of the MR exam itself in real time.  Additionally, the documentation for CPT code 76018 should address the programming performed to put the device into safe mode, or other appropriate programming, while the patient is in the MR suite and prior to the examination. If the device was put in safe mode in a separate office, i.e., outside of the MR suite in the neurologist/cardiologist's office, CPT 76018 is not separately billable. Documentation should also address that the device was returned to normal mode following the scan, as appropriate, and signed.

 

The AMA provides the following clinical example for CPT code 76017:

 

"Clinical Example Summary: An MRI is ordered for a patient presenting with new seizures and weakness. The patient has a deep brain stimulator (DBS) for Parkinson's disease. The DBS has MR conditions restricting scan time and energy deposition. MR conditions of the DBS, including scanner idle times to allow for device cooling, are met by a medical physicist who customizes and monitors the performance of the MR exam interactively. The medical physicist performs these services under the supervision of a radiologist who reviews MR images and provides feedback to the medical physicist in real time to determine if any scan parameter adjustments or additional views are needed. The radiologist considers cutting additional views from protocol in order to avoid exceeding any total scan time restrictions of the DBS. Any limitations to the MR examination that are related to the DBS system affecting the diagnostic quality and interpretation of the MR examination should be documented in a written report."

 

The AMA provides the following clinical example for CPT code 76018:

 

"Clinical Example Summary: A patient with a DBS has their device modified into an MR safe mode in the MR suite prior to the exam. The device programming is performed in a safe area away from the scanner, where the patient also gets their IV started before the MR examination begins. After the MR examination is completed, the device is turned back on in a safe area, where the patient also changes their clothes."

 

Some devices or implants may have the potential to migrate when exposed to the MR environment. There are manufacturer instructions on properly immobilizing the patient to keep the device from moving. For example, a patient with a cochlear implant, which uses an internal magnet that can only be removed with surgical intervention, may require a compression headwrap to mitigate the risk of the implant moving during the MR examination. Because there is a risk to the patient by exposing them to the MR environment, this service requires an informed consent discussion with the patient prior to the MR examination. CPT 76019 represents the immobilization or positioning of a device for a safer MR exam. Report documentation should include the specific device and potential to migrate, any manufacturer instructions to immobilize the device, risk to the patient and device by placing them in the MR field, and an informed-consent discussion with the patient before the exam.


The AMA provides the following clinical example for CPT code 76019:

 

Clinical Example Summary: An MRI of the brain is ordered for a patient with an auditory brainstem implant (ABI). The ABI has MR conditions for an internal magnet, which require the application of a head wrap to immobilize and secure the device. Because there is a risk to the patient and to the ABI when entering the MR field, this service requires a discussion with the patient prior to the start of the MR examination. Informed consent must be obtained from the patient before proceeding with the MR examination.


The ABI is immobilized according to the implant manufacturer's MR conditional instructions. The physician or QHP monitors the patient's condition during positioning and introduction into the MR exam room. The patient is introduced and removed slowly from the MR examination. The examination is discontinued if the patient cannot tolerate the pain, after which the immobilization wrap is removed, and the ABI location is checked for any evidence of implant migration, malfunction, or tissue damage. The patient is provided with educational materials. Any implant positioning and immobilization precautions, as well as recommendations for future MR examinations, are documented in a written report."

 

With these updates, ensuring compliance and accurate documentation is more important than ever.

 

Teri Bedard, BA, RT(R)(T), CPC, is Executive Director of Client and Corporate Resources at Revenue Cycle Coding Strategies (RCCS).

 

www.rccsinc.com

 

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Navigating the Maze of ASC Claim Denials: Proven Strategies for a Seamless Process

Coding

Navigating the Maze of ASC Claim Denials: Proven Strategies for a Seamless Process:As ambulatory surgical centers (ASCs) experience a surge in case volume due to a growing recognition of the efficiency, cost-effectiveness, and patient convenience they offer, the potential for revenue growth is matched by the heightened risk of billing and coding errors, making the fight against denials more daunting than ever.
How Lab Benefits Management Can Smooth the Transition to Value-Based Care

Coding

How Lab Benefits Management Can Smooth the Transition to Value-Based Care:Switching the U.S. healthcare system from the traditional fee-for-service model to value-based care is an enormous undertaking. It requires no less than changing how healthcare is thought of, delivered, measured, and paid for.
Understanding the Changes in the CMS-HCC Model V28

Coding

Understanding the Changes in the CMS-HCC Model V28:The New Year brought with it a long-overdue overhaul of the Centers for Medicare and Medicaid Services (CMS) hierarchical condition categories (HCC), ushering in the 28th version of the model used to assign risk adjustment factor (RAF) scores and estimate future healthcare costs for Medicare Advantage patients.
Coding for Zika: Unraveling the Threat of a Silent Predator

Coding

Coding for Zika: Unraveling the Threat of a Silent Predator:When we consider treacherous animals, our thoughts may drift to lions, bears, and sharks. Yet, the true menace is a far less conspicuous creature: the mosquito. This seemingly harmless insect can spread many deadly diseases, including Zika, dengue fever, yellow fever, and West Nile virus. In this article, our focus is on the Zika virus, exploring its means of transmission, presenting symptoms, diagnostic methods, and available treatments. Furthermore, we shed light on medical coding for Zika, providing nine detailed examples to simplify the accurate assignment of ICD-10-CM codes in accordance with established guidelines and conventions.
How Are Radiology Practices Impacted by Annual Changes to the Medicare Physician Fee Schedule?

Coding

How Are Radiology Practices Impacted by Annual Changes to the Medicare Physician Fee Schedule?:With passage of the Consolidated Appropriations Act, 2024 (CAA 24), we finally learned the rates that physicians will be paid for Medicare services during the remainder of 2024. Effective when it was signed by the president on March 9, 2024, the CAA 24 contained several provisions that benefitted physician reimbursement:
Coding Changes That Will Impact Radiology Practices in 2024

Coding

Coding Changes That Will Impact Radiology Practices in 2024:The annual update to the Current Procedural Terminology (CPT)® for 2024 has 230 new codes, 70 revised codes, and 49 deleted codes. In addition, there are 395 new diagnosis codes contained in the ICD-10-CM update, about one-third of them describing new ways to capture accidents and injuries. Although relatively few of these changes will impact radiology practices, it's essential to know what they are and adjust your practice systems accordingly.
Breaking Down Misconceptions: Understanding Thyroid Diseases

Coding

Breaking Down Misconceptions: Understanding Thyroid Diseases:Imagine a tiny butterfly-shaped gland quietly regulating your body's energy levels and overall health. Your thyroid, which uses iodine to make thyroid hormones, helps control blood pressure, body temperature, heart rate, metabolism, and the reaction of your body to other hormones. Thyroid disorders occur when the gland becomes overactive (hyperthyroidism) or underactive (hypothyroidism). When the thyroid is not working as it should, it can result in serious health problems.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)

Coding

ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD):Chronic Obstructive Pulmonary Disease (COPD) is a progressive and persistent inflammatory lung disease resulting in limited airflow. Primary causes of COPD are long-term exposure to irritating gases or particulate matter, most commonly from cigarette smoke. There are multiple factors that can contribute to the development of COPD, such as:
Demystifying EKG and Telemetry for the Non-Clinician

Coding

Demystifying EKG and Telemetry for the Non-Clinician:Electrocardiograms (EKG or ECG) and telemetry are indispensable tools in the field of cardiac health. They have revolutionized how healthcare professionals diagnose and monitor various heart conditions, from arrhythmias to heart attacks. EKGs record the heart's electrical activity, while telemetry involves wireless data transmission from a patient's heart to a healthcare provider.
Valentine's Day - From Romance to Responsibility: STD Awareness

Coding

Valentine's Day - From Romance to Responsibility: STD Awareness:>Love is in the air, and hearts are excited as we celebrate Valentine's Day. Yet, amidst the whispered promises and tender embraces, we need to remember that pure love is about caring for each other's well-being. Regular testing is essential for anyone who is sexually active to avoid STIs 365 days a year. Getting tested is necessary to give love and maintain your sexual well-being. More than flowers, chocolates, or champagne, knowing the facts about STDs and taking the necessary precautions are the best ways to celebrate love responsibly, passionately, and to its fullest.
Navigating Healthcare Claims and Audits for Purchased Diagnostic Testing

Coding

Navigating Healthcare Claims and Audits for Purchased Diagnostic Testing:Navigating Healthcare Claims and Audits for Purchased Diagnostic Testing: In the complex world of healthcare, accurate reporting of services is crucial for ensuring quality patient care and fair compensation for medical providers. One significant aspect of this process involves purchased diagnostic testing, where medical tests are conducted outside the healthcare organization. In this tip, we'll delve into the essentials of healthcare claim reporting and the auditing process related to purchased diagnostic testing.
Fathom Announces Partnership with Google Cloud, Adding its Autonomous Medical Coding Solution to Google Cloud Marketplace

Coding

Fathom Announces Partnership with Google Cloud, Adding its Autonomous Medical Coding Solution to Google Cloud Marketplace :This collaboration will boost access and integration with best-in-class autonomous medical coding for healthcare providers.
Modifier -25: Interpretation Is In The Eye of the Beholder

Coding

Modifier -25: Interpretation Is In The Eye of the Beholder :Fresh insights from the American Medical Association (AMA) are always welcome when it comes to medical coding policy. Although they have provided previous guidance on the appropriate use of modifier -25, the AMA's
Should I Report the Symptom or Confirmed Diagnoses for Testing?

Coding

Should I Report the Symptom or Confirmed Diagnoses for Testing?:Coders frequently ask questions about the guidelines surrounding coding symptoms vs. confirmed diagnoses, especially when tests are ordered during an encounter to rule out a condition, illness, or disease.
Optimizing HCC Coding for Accurate Reimbursement

Coding

Optimizing HCC Coding for Accurate Reimbursement:Hierarchical Condition Category (HCC) codes are an integral aspect of healthcare’s ongoing transition from fee-for-service to a value-based care model of reimbursement—a transition that requires providers to better manage patient costs based on a clear, concise, and comprehensive picture of patients’ health and medical conditions.
Understanding CPT Code Range 92920-93793 in Cardiology Billing

Coding

Understanding CPT Code Range 92920-93793 in Cardiology Billing :The realm of cardiology encompasses a vast array of specialized services and procedures, demanding precise documentation and accurate coding for proper reimbursement. Understanding the specific CPT codes within the range of 92920-93793 is crucial for healthcare providers navigating this complex landscape. This article serves as a detailed guide, unpacking the details of this CPT code range 92920-93793 and its applications within cardiology billing.
Missing HCC Codes Leave Money on the Table

Coding

Missing HCC Codes Leave Money on the Table:Improper clinical documentation of one patient can mean a difference of more than $10,000 in yearly estimated healthcare costs. How much money are you potentially leaving on the table?
Big Changes Will Streamline CPT Coding for Immunization

Coding

Big Changes Will Streamline CPT Coding for Immunization :Significant changes in the Current Procedural Terminology (CPT ® ) code set for immunizations reflect the changing nature of how COVID-19 is being addressed as actions transition from a public health emergency response to combatting emerging variants much like the flu.
Time Changes for 2024

Coding

Time Changes for 2024:Beginning January 1, 2024, providers utilizing time for leveling an office and/or outpatient Evaluation and Management (E/M) service must meet or exceed the minimum threshold total service time. This change for 2024 better aligns with time changes that were already made in 2023 for inpatient settings.
The Impact and Challenges of Sequencing Z Codes for Reimbursement

Coding

The Impact and Challenges of Sequencing Z Codes for Reimbursement :Every year, we get updates to the Official Guidelines for Coding and Reporting, and this year, for reporting year 2024, we received an update regarding Chapter 21 for follow-up codes Z08 and Z09. The accurate sequencing of these Z codes was emphasized in the guideline update by reminding us that they can be used for both medical and surgical treatment.
Updated ICD-10-CM Codes for Appendicitis

Coding

Updated ICD-10-CM Codes for Appendicitis :According to JAMA, there are approximately 250,000 cases of appendicitis diagnosed annually in the United States. Appendicitis can quickly spiral out of control when a perforation of the appendix occurs, and a patient becomes septic. Understanding the language used in medical documentation helps with the proper assignment of ICD-10-CM codes and supports testing and treatment.
Update on Policy for Using Modifiers JW and JZ

Coding

Update on Policy for Using Modifiers JW and JZ:JW has been a requirement since 2017; however, Medicare is using the JW modifier and JZ modifier to calculate discarded drug refunds, effective January 1, 2023. 
Capturing HCCs in a Changing World

Coding

Capturing HCCs in a Changing World:On March 31, 2023, the Centers for Medicare and Medicaid Services (CMS) released the CY 2024 Medicare Advantage (MA) Capitation Rates along with Part C and Part D payment policies.  The largest key decision in the release was the finalized proposal to revise the Medicare Advantage Risk Adjustment model.
Aetna Reimbursement Policy: Radiology Modifiers

Coding

Aetna Reimbursement Policy: Radiology Modifiers:According to provider October updates: Aetna will reduce the reimbursement rate for HCPCS radiology codes when modifiers FX and FY are appended.
Reviewing the Guidelines for Reporting ICD-10-CM Aftercare Codes

Coding

Reviewing the Guidelines for Reporting ICD-10-CM Aftercare Codes:Aftercare codes are assigned to explain encounters where the initial treatment of a disease has been completed and the patient encounter is now focused on aftercare for healing and recovery. These codes may also be reported to explain long-term consequences of the disease. 
COVID Vaccine Coding Changes as of November 1, 2023

Coding

COVID Vaccine Coding Changes as of November 1, 2023:Correctly coding the administration of COVID-19 vaccines had become such a huge burden for providers.
2024 ICD-10-CM Code Changes

Coding

2024 ICD-10-CM Code Changes:It's that time of the year again.  The new ICD-10-CM code books are out, and the changes are now active.  There are 395 new diagnosis codes, 25 deleted codes, and 12 revised codes for 2024.  As a healthcare professional, the ability to understand and navigate the updated ICD-10-CM codes is integral. Mistakes or misunderstandings can lead to claim denials, inaccurate data collection, and potential patient harm.  It is vital to engage in continued education to understand these changes fully.  This article will provide an overview of the new codes for  ICD-10-CM for 2024.
Truly Autonomous Coding Requires a Multifaceted Solution

Coding

Truly Autonomous Coding Requires a Multifaceted Solution:Coding technology has come a long way since the days when Computer-Assisted Coding (CAC) was a bleeding edge feature of the more advanced encoder solutions. Today's CAC solutions are often integrated with Clinical Documentation Integrity (CDI) tools and have automated much of the coding process.
Why Support for H.R. 2474 Is Important to Your Radiology Practice

Coding

Why Support for H.R. 2474 Is Important to Your Radiology Practice:The Strengthening Medicare for Patients and Providers Act (H.R. 2474) would modify the way the Medicare Physician Fee Schedule (MPFS) is calculated and adjusted each year.  The basic system of determining Relative Value Units (RVU) would not change, but the annual adjustment of the Conversion Factor (CF) would more closely reflect the actual economic factors that affect physicians' practices.
Pediatric Craniosynostosis Coding in ICD-10-CM

Coding

Pediatric Craniosynostosis Coding in ICD-10-CM:Craniosynostosis, a complex craniofacial condition, impacts approximately one in every 2,500 babies in the United States. This article delves into the complexity of this congenital disability, shedding light on its various forms, categorized broadly by either an unknown cause or an underlying condition. Moreover, we explore ICD-10-CM coding for these diagnoses, including the recent updates as of October 1 of this year, designed to reflect the diverse types of craniosynostosis.
Radiology Practices Struggle to Avoid Penalties in the Medicare Quality Payment Program

Coding

Radiology Practices Struggle to Avoid Penalties in the Medicare Quality Payment Program:For many radiology practices, the idea of a positive payment adjustment for participation in the Medicare Quality Payment Program (QPP) has been lost.  Several factors have combined over the past few years to change the goal for radiology practices - it is now "penalty avoidance" rather than a reward for reporting quality metrics.  As outlined in Healthcare Administrative Partners' recent review of the Medicare 2024 Physician Fee Schedule Proposed Rule, the QPP requirements for successful participation are going to become even stricter.
The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance

Coding

The 2024 ICD-10-CM Updates Include New Codes for Reporting Metabolic Disorders and Insulin Resistance:The ICD-10-CM annual updates scheduled for implementation on October 1, 2023, include 395 new codes, 25 deleted codes, and a total of 13 revised codes. Among the newly added codes are codes that better define metabolic disorders, such as metabolic syndrome, also known as insulin resistance syndrome, dysmetabolic syndrome, hypertriglyceridemic waist, obesity syndrome, and Syndrome X. 
Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding

Coding

Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding:GERD stands for Gastroesophageal Reflux Disease, a chronic condition where stomach acid flows back into the esophagus, causing a range of symptoms, such as heartburn, regurgitation, chest pain, difficulty swallowing, and a chronic cough.
ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2023 Update

Coding

ICD-10 & Other Coding Revisions to National Coverage Determinations: October 2023 Update:CR 13166 is a maintenance update of ICD-10 conversions and other coding updates specific to NCDs.
E/M Scoring Questions

Coding

E/M Scoring Questions:Evaluation and Management visits are often the "bread and butter" of an organization. Thus, correctly scoring encounters is essential to ensuring proper reimbursement. The element of "Risk" is only one of the three elements of Medical Decision Making (MDM) but understanding what is meant by all the definitions within each element is critical. 
Medical Necessity and Data Under the E/M Documentation Guidelines

Coding

Medical Necessity and Data Under the E/M Documentation Guidelines:Whenever I audit charts under the 2021 E/M Documentation Guidelines, which now apply in all places of service, I like to start by reviewing the first and third columns. The first column is Number and Complexity of the Presenting Problem, and the third column is Risk of Complications and/or Morbidity or Mortality of Patient Management.
Coding Critical Care Services in 2023

Coding

Coding Critical Care Services in 2023:Critical care services refer to the delivery of medical care to the critically ill or injured patient by a qualified physician or other qualified healthcare professional (QHP). Current Procedural Terminology (CPT) defines a critical illness or injury as one that "acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition." 
PSQIA, PSWP, and HIPAA Compliance

Coding

PSQIA, PSWP, and HIPAA Compliance:This article addresses patient confidentiality and security related to patient safety evaluation systems, investigations, root cause analyses, and compliance to rules and regulations.  It is a basic introduction to help understand the importance of appropriately managing this type of privileged information.
ICD-10 Codes to Report Cataracts

Coding

ICD-10 Codes to Report Cataracts:Cataracts, a leading cause of vision loss in the United States, occur when the normally clear lens of the eye becomes clouded. This clouding obstructs or alters the passage of light into the eye, resulting in impaired vision. Ophthalmic surgeons perform safe and effective surgery to treat cataracts. Professional medical billing and coding companies can assist physicians with coding and claims submission tasks.
Understanding Skin Biopsy CPT Codes: A Comprehensive Guide

Coding

Understanding Skin Biopsy CPT Codes: A Comprehensive Guide:Skin biopsy plays a crucial role in the diagnosis and management of various dermatological conditions. To accurately report and bill for these procedures, healthcare providers rely on Current Procedural Terminology (CPT) codes. CPT codes are standardized numerical codes used to describe medical procedures and services. In this article, we will delve into the world of skin biopsy CPT codes. Understanding these codes can help family physicians code and bill skin biopsy procedures correctly, ensuring optimal reimbursement and proper documentation.
The Transition to ICD-11: A Major Step Forward for Global Health

Coding

The Transition to ICD-11: A Major Step Forward for Global Health:During the late 1800s, a physician from France named Jacques Bertillon was developing a method to create a consistent way of categorizing diseases. His goal was to simplify the process of monitoring and comparing mortality rates across various nations. In 1893, he released the inaugural version of the International Statistical Classification of Diseases, which is currently recognized as the International Classification of Diseases - ICD.
Overcoding: Putting a Strategic Stop to a Silent Revenue Killer

Coding

Overcoding: Putting a Strategic Stop to a Silent Revenue Killer:Overcoding is in the crosshairs as the Centers for Medicare and Medicaid Services (CMS) continues its quest to ferret out fraud and abuse and recoup improper reimbursements-a focus that returns $8 for every $1 spent on audits. There are no signs that they are letting up any time in the future, as the federal government has increased funding for audits and fraud investigations. 
Identifying the Admitting, Principal, Primary, and Secondary Diagnoses

Coding

Identifying the Admitting, Principal, Primary, and Secondary Diagnoses:Knowing how to differentiate the admitting, principal, primary, and secondary diagnoses for reporting and sequencing purposes can be intimidating and confusing. The following are some commonly asked questions related to reporting diagnoses in the facility setting. 
Combination Codes Provide Greater Detail for Complicated Conditions

Coding

Combination Codes Provide Greater Detail for Complicated Conditions:When ICD-10-CM was initially implemented, it was like watching the Discovery Channel, where new codes and guidelines seemed to appear, along with new guidelines for how to report them.
Identifying the Components of a High-Risk Evaluation and Management Service

Coding

Identifying the Components of a High-Risk Evaluation and Management Service:Since 2021, when the Office and Other Outpatient Evaluation and Management (E/M) services coding guidelines changed to require only scoring by time or medical decision making (MDM), coders, providers, and facilities have worked hard to implement changes that would facilitate correct coding through clear documentation and well-formatted templates. 
Defining Modifier 25

Coding

Defining Modifier 25:Yes! Considering the recent uproar caused by one payer's plan to implement a policy requiring prepayment review of documentation for all visits billed with 99212-99215, modifier 25, and a minor procedure, it is clear there is still a need to discuss this often-misused modifier.
Are You Properly Reporting Radiology Services?

Coding

Are You Properly Reporting Radiology Services?:It's probably not surprising that the most commonly billed imaging services are radiologic examinations of the humerus, spine, fingers, and abdomen (codes 72070, 73060, 73140, and 74019).
If a Procedure Was Not Documented, Was It Performed?

Coding

If a Procedure Was Not Documented, Was It Performed?:Most of us, if not all of us, have heard the statement, "If it isn't documented, then it wasn't performed." While I know this is often the perspective of payers, I cringe when I hear this, thinking about all the providers that I work with and the fact that it may not be a true statement that the procedure was not done.
How Can Radiology Networking Improve Your Practice?

Coding

How Can Radiology Networking Improve Your Practice?:A large metropolitan-area radiology group covers several departments within a hospital system.  They have on-site staff daily at each location to handle all modalities, including sub-specialists to be sure pediatric, neuro, and body imaging are handled with the right expertise.  

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