What Every Radiologist Should Know about Coding

keyboardYou’ve read your study and dictated your report. What’s next?

Your report goes to a medical coder who reads the report and assigns the appropriate CPT®, ICD-10-CM, and HCPCS Level II codes so you can get paid. It sounds straightforward, doesn’t it? It’s not.

In the coding process, there are many ways to get from your completed dictation to being paid for the work. Let’s discuss a few.


All Coders Are Not Equal

The first thing you want to know is are the people doing your coding certified? There are three generally accepted certifications in radiology coding. These include:

CPC:  There are CPC coders who are certified for generic medical coding (all specialties), and some CPC specialty coders. A radiology-specific coding specialty is not offered. These coders are certified by the AAPC.

The CPC coders come in two flavors: CPC-A which means they are an apprentice and CPC which means they have finished their apprenticeship.

RCC:  There is also the Radiology Certified Coder (RCC) which is offered by the RBMA. According to the RBMA, “The Radiology Coding Certification Board (RCCB) is a not-for-profit organization established in May 2000, to promote the highest standards of radiology coding through the credentialing of radiology coders.”

CCS:  CCS (hospital coding) and CCS-P (physician coding) are offered by AHIMA.  

Any of these certifications are fine, but it is key that the people coding your report are certified. Each certification path requires rigorous study and exam completion as well as continuing education. If your coding is being done by a non-certified coder, you have a significant exposure that your coding is being done incorrectly. This can cost you money, and the risk of an audit.

One final note—there are certified interventional radiology coders (CIRCC). If you are doing a fair amount of complicated IR procedures, it behooves you to seek coding from a certified interventional coder. A typical CPC or RCC coder is likely not equipped with enough IR experience.


Computer Assisted Coding (CAC)

Computer-Assisted Coding is the process of using Natural Language Processing to read, interpret, and electronically code the report. Human coders are expensive, so organizations have attempted to reduce the cost by using CAC.

CAC is nothing more than a tool—how it’s being used is the primary concern. Many organizations use CAC then bill directly without the report ever being reviewed by a certified coder. Depending on the report’s complexity, and the number of codes used, this can greatly affect the quality of the coding.

Dexios tried CAC, but ultimately gave it up in 2012 because we weren’t satisfied with the quality of results. From a billing company perspective, you must at least cover your costs and have equal or better quality for CAC to make sense. It may for others, but not for us.


Overseas Coders

Another cost-savings measure is to outsource coding needs overseas. As we mentioned, coders are expensive so it’s logical to look offshore in countries such as India where wages are much lower. Again, as with the topic of certified coders, it is critical to know your coding is being done by someone who is qualified to do the work.

Dexios has also experimented with overseas coding. Like CAC, we were not happy with the quality of the work and stopped using overseas providers.



It goes without saying—people don’t do what they are expected to do, they do what they are inspected to do. Be prepared for periodic quality control audits, don’t skip out on them. It’s worthwhile to note that there are required certifications for coding auditors.

Dexios Coding

  • 100% of Dexios coders are certified.
  • Dexios interventional radiology coding is done by certified IR coders.
  • None of our coding is done via CAC.
  • All our coders are US-based.

To begin your free analysis and audit, or for more information on our full suite of billing & coding services, contact Dexios today.

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