C. Douglas Phillips, MD Bruce J. Hillman, MD Index terms: Cost-effectiveness Radiology and radiologists, departmental management Radiology reporting systems Radiology 2001; 220:7–11 Abbreviations: CPT = Current Procedural Terminology ICD = International Classification of Diseases S&I = supervision and interpretation 1 From the Department of Radiology, University of Virginia Health System, Box 800170, Charlottesville, VA 22908. Received December 6, 1999; revision requested January 21, 2000; revision re- ceived July 6; accepted July 14; updated February 8, 2001. Address corre- spondence to C.D.P. (e-mail: cdp9m @virginia.edu). © RSNA, 2001 Coding and Reimbursement Issues for the Radiologist 1 Radiologists are dependent on the proper execution of a complex administrative chain of disease and diagnosis coding and procedural coding to be properly reimbursed for the examinations they perform. The radiologist bears the ultimate responsibility for the appropriateness of these codes. However, many practicing radiologists are unaware of the critical link between the two coding systems and the systems that have developed to provide a common method of describing diseases, diagnoses, and procedures. This article is an introduction to these systems, and it emphasizes the importance of the involvement of the radiologist in coding. The inherent complexity of the reimbursement system in use is emphasized, as well as the essential role of the radiologist in complying with these often complicated and ever-changing directives. Organizing and managing a successful radiology department has become more complex and technical than in the past partly because of the greater complexity in the physician reimbursement system that has placed new demands on radiologists and departmental administrators. The difference between a radiologist’s charges and what is collected has widened. Specifically, the contracted and discounted fee for service and the bundled payment schemes such as capitation have reduced the payment per unit of service. Insurers have grown more aggressive (some would say more passive-aggressive) in devel- oping strategies to reduce what they have to pay. Payment is frequently delayed for bills that are submitted in good faith by radiologists (1). Radiologists’ charges may be returned for clarification or requests for additional clinical information, or they may be rejected for reasons that are often unclear. These trends are likely to continue as payers seek to reduce their medical-loss ratio (the amount paid for medical services divided by all costs, includ- ing medical services, administration, capital, and return to investors) (2). Hence, it is essential to manage the finances of the department to minimize the loss of collectable revenue. Issues on which radiology departments can focus to improve their collections include proper patient registration, insurance verification, and, more important, appropriate cod- ing of completed examinations. The last of these issues, correct coding, is probably the most arcane. To make matters worse, the rules governing coding are constantly changing. A submitted claim must clearly reflect, by means of the attached codes, what was done and why it was done, and it must meet the payer’s expectations that the two are appropriately and plausibly related. The purpose of this special review is to set forth principles that govern coding to help radiologists understand the coding system and improve the success of their claims submissions. The best means to arrive at a consistent description of a radiologic procedure or examination is shared terminology. For these procedures, the Current Procedural Terminol- ogy (CPT) manual (3) is the reference. Similarly, the description of a disease process must be consistent to allow coding of a diagnosis that may necessitate a radiologic procedure or examination. The system used to discuss the disease processes is the International Classi- fication of Diseases (ICD). The following sections will discuss the importance of the CPT and ICD systems, the reason why physicians should be familiar with both, and the utilization of these manuals to ensure optimal coding. THE CPT SYSTEM Coding of an imaging procedure requires the provision of one or more procedural (CPT) codes and one or more diagnostic (ninth revision of ICD) codes (4). The CPT handbook is Special Review 7