Hello,
Any site I have worked at in the hospital setting has always used outpatient ICD-10-CM guidelines when coding radiological procedures even when the patient is inpatient. Why is this, what guideline supports this? Or should we be truly following IP guidelines if that patient is inpatient even when reporting the ProFee components?
Radiological procedures are often coded using outpatient ICD-10-CM guidelines, even when performed on inpatients because of how professional fee (ProFee) coding operates to facility (hospital) coding. Here’s why:
1. Professional Fee (ProFee) Coding vs. Facility Coding
Facility inpatient coding (UB-04 claims): Uses ICD-10-CM for diagnosis coding and ICD-10-PCS for procedure coding, following inpatient-specific guidelines.
Professional fee coding (CMS-1500 claims): Uses ICD-10-CM for diagnoses and CPT/HCPCS for procedures (not ICD-10-PCS).
Since radiologists bill separately for their interpretation and use CPT codes for procedures, they follow outpatient coding rules even when the patient is an inpatient.
2. Supporting Guidelines
ICD-10-CM Official Guidelines for Coding and Reporting (Sections II and IV)
Section II (Selection of Principal Diagnosis for Inpatients) applies to facility coding.
Section IV (Diagnostic Coding and Reporting for Outpatient Services) applies to ProFee coding, including radiology services.
Since ProFee coding follows CPT guidelines, it aligns with outpatient coding practices, even in an inpatient setting.
Medicare and Payer Guidance
Medicare and commercial payers require radiologists to use CPT and outpatient ICD-10-CM guidelines for billing ProFee services.
This is because radiology is typically considered an outpatient-like service in terms of billing, even when the patient is inpatient.
3. Radiology-Specific Billing
The technical component (TC) is billed by the hospital, which follows inpatient coding guidelines.
The professional component (PC) (interpretation by the radiologist) is billed separately and follows outpatient ICD-10-CM coding rules.
Even if a patient is inpatient, the radiologist’s professional services are coded with outpatient ICD-10-CM guidelines because the ProFee component follows CPT-based rules, not inpatient facility guidelines. However, the hospital coding for the technical component adheres to inpatient rules (ICD-10-PCS).
Here are the specific references supporting the practice of using outpatient ICD-10-CM guidelines for coding radiological procedures, even when the patient is inpatient:
CMS Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures:
This manual clarifies that the technical component (TC) of radiology services for hospital inpatients is included in the hospital's prospective payment system (PPS) and is not separately billable by suppliers. However, the professional component (PC), which pertains to the physician's interpretation, is billed separately under the Medicare Physician Fee Schedule (MPFS). This distinction necessitates the use of CPT codes and outpatient ICD-10-CM guidelines for professional services, regardless of the patient's inpatient status.
Reference: CMS Medicare Claims Processing Manual, Chapter 13
Noridian Healthcare Solutions – Billing Radiology Services Professional and Technical Components:
Noridian, a Medicare Administrative Contractor, explains that imaging services are divided into technical and professional components, each separately billable. The professional component, representing the physician's interpretation, is billed under the MPFS using CPT codes, adhering to outpatient coding guidelines, even when services are provided to hospital inpatients.
Reference: Noridian – Billing Radiology Services Professional and Technical Components
CMS National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 9 – Radiology Services:
The NCCI Policy Manual outlines that physicians should report the HCPCS/CPT code that accurately describes the procedure performed. The professional component of radiology services involves using CPT codes in conjunction with outpatient ICD-10-CM guidelines, irrespective of the patient's inpatient status.
Reference: CMS NCCI Policy Manual, Chapter 9
These references collectively support the practice of applying outpatient ICD-10-CM guidelines for coding the professional component of radiological services, even when the patient is an inpatient. This approach aligns with Medicare's billing requirements and ensures accurate reimbursement for professional services rendered.
