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Radiology Compliance Question

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For the Week of July 14, 2014

Question:

If we performed a liver spleen static only...more

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For the Week of July 7, 2014

Question:

Is there a guideline that states that patients with a...more

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For the Week of June 30, 2014

Question:

We did a thyroid biopsy under ultrasound guidance...more

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For the Week of June 23, 2014

Question:

What code is assigned for a myelogram?...more

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For the Week of June 16, 2014

Question:

In the CCI, 32551 is the column one code...more

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For the Week of June 9, 2014

Question:

Can codes 93016 and 93018 be billed with 78454...more

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For the Week of June 2, 2014

Question:

What CPT code would we use if we obtained chest...more

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For the Week of May 26, 2014

Question:

When a SPECT scan and CT scan are done...more

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For the Week of May 19, 2014

Question:

When a SPECT scan and CT scan are done...more

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For the Week of May 12, 2014

Question:

Do we consider CT post discogram as with contrast...more

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For the Week of May 5, 2014

Question:

Our facility performs a two-view chest x-ray to identify...more

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For the Week of April 28, 2014

Question:

For 78452 we will at times only perform the stress...more

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For the Week of April 21, 2014

Question:

Can you provide guidance about assigning code...more

 

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For the Week of April 14, 2014

Question:

I am unable to find any guidelines as to when...more

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For the Week of April 7, 2014

Question:

Can you tell me what the global period for an...more

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For the Week of March 31, 2014

Question:

How should a cardiac viability study be coded?...more

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For the Week of March 24, 2014

Question:

Can a physician's office make a profit on the rubidium...more

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For the Week of March 17, 2014

Question:

Are there any new radiopharmaceutical codes for...more

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For the Week of March 10, 2014

Question:

How do the 2014 rules about coding a needle...more

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For the Week of March 3, 2014

Question:

What code would be used for a whole body CT in order to...more

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For the Week of February 24, 2014

Question:

If the radiologist’s dictation does not mention all of the organs...more

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For the Week of February 17, 2014

Question:

Can I bill the following codes together: 78452, 93016, and...more

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For the Week of February 10, 2014

Question:

Is a physician order for a "MPI in 6 months" acceptable...more

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For the Week of January 27, 2014

Question:

We are having troubles with insurance companies willing to...more

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For the Week of January 20, 2014

Question:

If a physical exam is performed in conjunction with a diagnostic ...more

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For the Week of January 13, 2014

Question:

Our radiology department staff asked me whether, when doing ...more

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For the Week of January 6, 2013

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My question relates to IV for CTA. Our radiologists are ...more

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For the Week of December 30, 2013

Question:

Can a radiologist use both the 1995 and 1997 documentation guidelines to document ...more

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For the Week of December 23, 2013

Question:

What codes are used to report stress agents under the OPPS ...more

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Week of December 16, 2013

Question:

If stents are placed in both the right and left common iliacs, do we assign code 37221 twice... READ MORE

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Week of December 9, 2013

Question:

When the physician's order states pelvic ultrasound and during the exam it is determined that a transvaginal ultrasound... READ MORE

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Week of December 2, 2013

Question:

I see that there are new percutaneous drainage codes in the 2014 CPT. Can radiological guidance... READ MORE

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Week of November 25, 2013

Question:

What is Medicare policy related to administering contrast orally... READ MORE

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Week of November 11, 2013

Question:

What date of service (DOS) should be billed for the professional component (PC), or interpretation, of a... READ MORE

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Week of November 4, 2013

Question:

Would you explain the difference between code 93460 and 93453? They both look like they are for a LHC... READ MORE

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Week of October 28, 2013

Question:

Our oncology department has started ordering what they call a “skeletal survey” for melanoma... READ MORE

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Week of October 21, 2013

Question:

We have an endocrinologist doing fine-needle aspirations of the thyroid. Can he charge... READ MORE

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Week of October 14, 2013

Question:

When is it appropriate to assign HCPCS level II code C9399... READ MORE

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Week of October 7, 2013

Question:

We are starting a new procedure in our hospital surgery department that involves... READ MORE

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Week of September 16, 2013

Question:

When doing a thyroid whole body (CPT 78018), is it necessary to have an additional order for the add-on CPT... READ MORE

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Week of September 9, 2013

Question:

How does Medicare pay for imaging performed for a skilled nursing facility (SNF) patient?... READ MORE

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Week of September 2, 2013

Question:

I am not sure what to charge for the following case. A patient came in on one day for a stress... READ MORE

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Week of August 26, 2013

Question:

We received a patient from the ER who presents with severe pelvic pain. The HCG indicates pregnancy, but there is no

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Week of August 19, 2013

Question:

Will CMS change the way it calculates hospital relative weights for radiology next year?

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Week of August 12, 2013

Question:

What code should be used when a screening sinus CT study is performed?

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Week of August 5, 2013

Question:

Should I code for one operative field or two when treating epistaxis bilaterally... Read More

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Week of July 29, 2013

Question:

How would you code for a liver / lung shunt study? 5 mCi technetium 99 MAA was... Read More

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Week of July 22, 2013

Question:

If a practitioner orders a complete abdominal echo (76700) and the patient’s gallbladder... Read More

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Week of July 15, 2013

Question:

How should an AAA be billed... Read More

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Week of July 8, 2013

Question:

Are PET/CTs reimbursed for patients with known Alzheimer's?

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Week of July 1, 2013

Question:

If an ultrasound is performed on each breast, can we assign code 76645 twice?... Read More

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Week of June 24, 2013

Question:

We are getting denials because, as stated, certain CT scans “are not based on medical necessity.” Can you define what is expected to meet this recommendation?... Read More

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Week of June 17, 2013

Question:

It seems that we are getting more denied claims for diagnostic tests even when we submit the documentation... Read More

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Week of June 10, 2013

Question:

In the past, our facility charged lower dollar amounts for children’s radiology procedures. The rationale... Read More

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Week of June 3, 2013

Question:

We have a physician who has asked our radiology director to perform ankle/brachial indices (ABI) at the hospital because he does not have the equipment in his office. The ABI will be performed, and the patient will take the printout back to the ordering physician to interpret. Can we charge for this in the hospital setting? If so, what is the CPT code for an ABI?

Answer:

There is no code for an ABI by itself. It is considered part of an evaluation and management (E & M) visit, or part of 93922–93924.

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Week of May 27, 2013

Question:

A patient comes in (hospital ED or hospital outpatient) for a chest x-ray. The physician order states, “chest PA and lat, additional for inspiratory and expiratory to r/o FB, 3 views total: inspiration PA, expiration PA and lat view.” These are all performed. Which codes would be assigned?

Answer:

Codes 71020 and 71035 would be coded for inspiration PA, expiration PA, and lateral chest x-rays. An inspiration PA is the "normal" PA/AP view. According to the American College of Radiology in Radiology Coding Source, an expiration PA is considered a special view.
71020 Radiologic examination, chest, 2 views, frontal and lateral;
71035 Radiologic examination, chest, special views (e.g., lateral decubitus, Bucky studies)

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Week of May 20, 2013

Question:

If I have a catheter selectively in the right SFA and take an angiogram and then advance the catheter into the right anterior tibial, can I code 36247 and 36248? And what happens if I proceed to angioplasty of the SFA but not the anterior tibial. Would I then change the 36248 into a 36247 for the anterior tibial?

Answer:

In reply to your first question: If a lower extremity angiogram is performed without revascularization, you would code only 36247 for the catheterization into the right anterior tibial. Since you have to go through the SFA to get to the right anterior tibial, you code only the farthest catheterization. If both the anterior tibial and the posterior tibial were catheterized, then you would code 36247 and 36248.

In reply to the second: Catheterization is included in 37224, and it would be inappropriate to add either 36247 or 36248 if the angiogram was performed from the same access. You can code a diagnostic angiogram supervision and interpretation code (75710-59) with 37224, but not a catheterization code.

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Week of May 13, 2013

Question:

The American Medical Association deleted code 75650 in 2013. How do you code for a diagnostic aortic arch angiogram with an upper extremity angio? No carotid angiography was performed.

Answer:

The correct coding would depend on what was actually done and documented. An arch study would be assigned 36221. If a separate extremity angiogram was also performed, then 75710 could be assigned. Using additional catheterization codes (36215–36217) with 36221 have not been clarified. One possibility would be to code 36221-52, along with 75710 and the appropriate extremity catheterization code (36215–36217). Check with your payer for guidelines.

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Week of May 6, 2013

Question:

We have a patient who had a CT-guided lung biopsy and then proceeded to have a CT-guided percutaneous gastrostomy tube placement. How do we code the CT-guided gastrostomy tube placement? Code 49440 includes fluoroscopic guidance but fluro was not used, only CT guidance.

Answer:

Unfortunately, CT-guided gastrostomy placement must be coded 49999—unlisted procedure, abdomen, peritoneum and omentum.

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Week of April 29, 2013

Question:

Our facility has recently started doing radioembolization (Y-90) procedures for hepatic tumors. On mapping day, we use 37204 and 75894 for embolization of vessels if needed. The patient returns on a different day for the radioembolization of the tumor. We are using 37204 and 75894 for the Y-90 radioemobilzation part of the procedure. Is this correct?

Answer:

There is no standard recommendation for coding these procedures. You should check with your individual payers and follow their instructions. (SirTex, the manufacturer of SirSpheres, includes a coding guide that lists three coding options on its website: http://www.sirtex.com/media/61003/2013_sirtex_coding_sheet_final_v_673-u-0213.pdf.

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Week of April 22, 2013

Question:

What documentation is required when reporting code 72010?

Answer:

Code 72010 is a survey of the entire spine instead of an evaluation of a specific level. Common uses would be to obtain measurements for scoliosis or to look for spinal metastasis. The images for this study are interpreted together as one report. Number of films is not a factor in choosing this code because it can range from 2 to 6. For instance, the entire spine of a small child may be evaluated on 1 AP view and 1 lateral view, but an adult spine may need AP and lateral films at each level (6 films)

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Week of April 15, 2013

Question:

Please elaborate on the correct coding for 36228 for the following scenario. Selective catheterization of the internal carotid artery with diagnostic angiography performed prior to intervention. Subsequently, the middle cerebral artery is selectively catheterized for intervention.

I believe that we only can charge 36224 and that the radiologist gets no additional CPT code to capture for his/her time and effort of catheterizing the MCA. Would 36228-52 be warranted?

Answer:

We have discussed this with our own consultants as well as consultants outside of our company, and we all believe that while the physician should be able to code 36228, he/she can't. This code specifies angiography, and if diagnostic angiography is not done in the selected cerebral vessels, then this code cannot be coded, and the radiologist gets no "credit" for the cerebral selections. We have submitted this question to the American Medical Association and others responsible for the codes, but as yet, we have not received any answer.

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Week of April 8, 2013

Question:

My question relates to coding for hospital outpatient radiology exams. Some of the patients that come in for MRI receive general anesthesia. Can we bill 01922 with revenue code 370 in addition to the MRI CPT code? The general anesthesia is given in the MRI suite and then the patient is taken to PACU (post-anesthesia care unit) for recovery. I see that CPT code 01922 has a status indicator of N, which is packaged, so I feel we should be able to bill this CPT code, but I cannot find any reference material on how to bill on a hospital claim.

Answer:

The Centers for Medicare & Medicaid Services (CMS) say that packaged codes should be assigned on claims even though there will be no separate payment, so you should assign 01992 along with all other codes associated with the procedure if general sedation is performed. The MRI code and charge would be listed, with the anesthesia code under that. For details about packaging, see the Medicare Claims Processing Manual, chapter 4, section 10.4 at http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf.

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Week of April 1, 2013

Question:

What is the proper way to code multiple injections? Here are the areas in question, which are all performed under ultrasound guidance in the same session on the same date of service: right glenohumeral, right subacromial/subdeltoid bursa, and right biceps tendon insertion.

Answer:

If separate sites are injected or aspirated, assign the following codes separately:

  • 20610 for right glenohumeral
  • 20610-59 for right subacromial/subdeltoid bursa
  • 20551 for right biceps tendon insertion.

Also assign 76942 for the ultrasound guidance. For Medicare, 76942 can only be coded once per session. Other payers may allow it per injection.

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Week of March 25, 2013

Question:

Now that the codes for thyroid uptake and scan have been split into 78012, 78013 and 78014, do we only need to use 78013 and 78014 for uptake and imaging or just 78014?

Answer:

The primary change for 2013 was that it no longer matters if one or multiple uptakes were measured. Just as before, when both imaging and uptake are performed, only the combined code is assigned. In 2013, that would be the following code:

78014 Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)

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Week of March 18, 2013

Question:

Our radiologists perform two views of the lumbar spine, three views of the thoracic spine, and three views of the cervical spine and provide a separate dictation per each anatomic area of the spine. Our local payer (BCBSRI) is denying 72040, 72070 and 72100 on claims submitted by the radiology practice. It wants us to bundle these codes into 72010 (radiologic examination, spine, entire, survey study, anteroposterior and lateral).

When we appeal (with supporting documentation), BCBSRI denies the appeal stating that we must submit 72010. I want to take this to the next level, but before I do that, I want to confirm that I'm right in interpreting 72010 as two views of the entire spine with dictation for the entire spinal survey instead of three separate reports.

Answer:

CPT code 72010 doesn't limit the number of films to two; in fact, it may include six or even more films (AP and lateral of the c-spine; AP and lateral of the thoracic spine; AP and lateral of the lumbar spine). The limiting factor is that this is a survey of the entire spine—for metastasis, scoliosis, trauma, etc. —and that one report is dictated to encompass the whole spine. If there is separate medical necessity for each area, and if each area is separately documented, you would assign the individual codes, according to CPT Assistant, January 2007.

One caveat to this direction is that when the exam was a survey, doing three separate reports should not be used as a reason to bill individual codes instead of 72010. In fact, it would be unusual to have individual exams of all three spinal regions. However, each individual payer can create their own rules since the Health Insurance Portability and Accountability Act (HIPAA) only requires that they use the codes not the guidelines.

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Week of March 11, 2013

Question:

If a two-day protocol for a nuclear stress test is done, what day would you bill the nuclear portion (78452)?

Answer:

Code 78452 could be assigned either the day the protocol started or the day it ended. Your facility should make a choice and be consistent about the policy. The radiopharmaceutical is coded for the day it is injected.

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Week of March 4, 2013

Question:

Can we assign 77055 for a verification of clip placement after biopsy?

Answer:

According to the American College of Radiology (ACR) Committee on Coding and Nomenclature, it is appropriate to code for a unilateral diagnostic mammogram (77055 or G0206) for verification of clip placement after biopsy when it is performed on a separate piece of equipment, if it is a different modality from the primary procedure or if separate physicians are involved.

However, according to the Centers for Medicare & Medicaid Services (CMS) in the NCCI Policy Manual(chapters 3 and 9), guidance codes for breast biopsy, needle localization, localization clip or other breast procedures include all imaging, and a post-procedure mammogram should not be coded.

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Week of February 25, 2013

Question:

Is it appropriate to report computer-aided detection (CAD) when performed in conjunction with breast magnetic resonance imaging (MRI), but when pharmacokinetic analysis is not performed?

Answer:

Yes, you should report category III code 0159T to describe CAD. This code should be used to describe any type of CAD performed in conjunction with an MRI of the breast.

Because this is an add-on code to breast MRI procedure, it must be reported in addition to one of the breast MRI without and/or with contrast codes (77058–unilateral; 77059–bilateral).

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Week of February 18, 2013

Question:

I would like to know if there is a specific CPT code for a shunt series on patients who come in for a verification of position. We currently charge for AP/LAT skull, AP/LAT neck, AP/LAT chest, and two-view abdomen. Shuntogram code 75809 appears to only be appropriate when contrast is used.

Answer:

There is not a single code for a non-contrast shunt series. You must assign individual body area x-ray codes. The tech and physician should be specific as to what was done. Based on the information in the question, this would be 70250, 70360, 71020, and 74010-52. (See Clinical Examples in Radiology, Summer 2005.)

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Week of February 11, 2013

Question:

Are routine supplies included (bundled) in a hospital’s Medicare reimbursement? And why is the payment so different when a procedure is performed in a hospital from an imaging center?

Answer:

If the physician is performing the service at a hospital or ambulatory surgical center (ASC), all of the technical charges (supplies, etc.) are part of the facility’s expense. Even if the physician were to bring his own staff and supplies, he or she can't code or bill for them. Outpatient hospitals can code and bill for some devices using the C-codes.

At doctor's offices and imaging centers, supplies (like catheters) are included in the professional expense (PE) relative value unit (RVU) and not coded separately. Drugs can usually be billed separately, as long as the drug is not one that is normally patient self-administered. The major difference between the hospital fee and physician fee relates to the PE portion. If radiologists (or other physicians) perform a procedure in their offices, the fee includes costs of room, staff, equipment, supplies, etc.

For more on this see the Medicare Claims Processing Manual, Chapter 12, section 20.4.4 at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.

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Week of February 4, 2013

Question:

What codes should be used to report thoracentesis?

Answer:

For claims with dates of service of January 1, 2013, and after, the American Medical Association (AMA) created four new codes to report thoracentesis, revised 32551, and deleted formerly used codes 32421and 32422. Two of the new codes listed below will be assigned if no imaging guidance is used, and the other two will be assigned if guidance is used.

32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance
32555 with imaging guidance
32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance
32557 with imaging guidance

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Week of January 28, 2013

Question:

How do we code a lumbar spine series with bending films? The views that we perform are anteroposterior (AP), lateral, spot, and bending views—five views. Would we assign 72114 (radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views)?

Answer:

If you are performing five views, even if two of them are bending views, you would assign code 72110, not code 72114. Code 72114 could be assigned, for example (and there are other options), when AP, lateral, both obliques, flexion and extension views are performed. To assign 72114, you must have a total of at least six views with one or more being bending (flexion, extension, left bending, right bending, etc.).

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Week of January 21, 2013

Question:

Can the following code be assigned if Doppler ultrasound is used for guidance instead of fluoroscopy?

36147 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)

Answer:

A. Code 36147 defines a fistulagram (angiogram) of a dialysis fistula (which would use fluoroscopy), and this code cannot be used for an ultrasound study. If you are doing a duplex study of an arteriovenous (AV) graft, see instead 93990 (duplex scan of hemodialysis access, including arterial inflow, body of access and venous outflow). If you are asking about using ultrasound guidance for access prior to an AV fistulagram, then you would assign code 76937 in addition to 36147, if the requirements are met.

76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)

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Week of January 14, 2013

Question:

Is it ok to separately report code 77052 with 77012?

Answer:

According to the latest version of the NCCI Policy Manual, if a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with radiologic guidance (e.g., 76942, 77012, 77021, 77031, 77032), the physician should not separately report a post-procedure mammography code (e.g., 77051, 77052, 77055–77057, G0202–G0206) for the same patient encounter. The radiologic guidance codes include all imaging required to perform the procedure.

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Week of January 07, 2013

Question:

When will code G9157 take effect to report US diagnostic procedures using TE Doppler for cardiac monitoring?

Answer:

The Centers for Medicare & Medicaid Services’ (CMS) have withdrawn their plan (announced via transmittal R2472CP) to have provider reports HCPCS level II code G9157 instead of unlisted code 76999 for ultrasound diagnostic procedures for transesophageal (TE) Doppler used for cardiac monitoring.Whether the agency will revise and/or reissue a new code in the future is unknown at this time.

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Week of December 31, 2012

Question:

We often have patients with existing ports present to the department for contrast exams. Our radiology nurse flushes the port prior to the contrast injection. Can CPT code 96368 be assigned in conjunction with a contrast study? I do not see any CCI edits but want to make sure.

Answer:

No. Flushing a catheter/port prior to drug delivery (including contrast) is considered an inherent part of the process and, therefore, should not be coded separately. Code 96368 is not used to report a flush but an intravenous infusion (for therapy, prophylaxis, or diagnosis). It is also an add-on code to 96365, 96366, 96413, 96415, and 96416, none of which would be coded during imaging exams. Code 96523 (irrigation of implanted venous access device for drug delivery systems) is available for routine flushing of a catheter, but it can only be assigned if that is the only service provided as noted in a CPT parenthetical note.

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Week of December 24, 2012

Question:

When is it appropriate to assign ICD-9-CM diagnosis code V71.1 for a positron emission tomography (PET) scan?

Answer:

Some Medicare payers will allow code V71.1, especially for PET for the initial treatment strategy. According to the Medicare national coverage determination (NCD) for PET for oncologic indications, this scan may be allowed for tumors that are “strongly suspected” based on diagnostic tests and clinical history. If the PET is done with negative results, V71.1 could be used to indicate that the physician suspected a malignant neoplasm.

Some payers also allow V71.1 for subsequent treatment strategy when the physician suspects a recurrence or metastasis that is subsequently disproven by PET.

The bottom line then: Check your payer’s local coverage determination (LCD) to see whether V71.1 is allowed.

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Week of December 17, 2012

Question:

The description for CPT code 70336 reads as “magnetic resonance (e.g., proton) imaging, temporomandibular joint(s).” Does this mean that the same CPT code would be assigned for unilateral and/or bilateral TMJs? If so, is a modifier required to differentiate left from right?

Answer:

Code 70336 is assigned once whether imaging is performed on one side or both sides. Modifiers are not necessary if a unilateral study is done—unless a payer requires it. Do not code separately as 70336-RT and 70336-LT.

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Week of December 10, 2012

Question:

Is it appropriate for a radiologist to upgrade or change an order from “limited” to “complete” ultrasound abdomen when the ordering physician has ordered ultrasound for organs in different systems or quadrants (i.e., liver, pancreas and kidneys or liver, spleen, pancreas, kidneys, gallbladder) done during the same session? If the answer is yes, the radiologist will need to include all areas in the report (liver, gallbladder, intrahepatic ducts, common bile ducts, pancreas, spleen, kidneys, aorta, and IVC).

Answer:

In the hospital situation (inpatient or outpatient) billing under the outpatient prospective payment system (OPPS), the radiologist can change the order from limited to complete if he can justify medical necessity for the individual patient, which must be documented. It cannot be done just per protocol.

If a complete exam is performed, all of the required elements must be documented. A complete abdominal ultrasound (76700) requires documentation of liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality.

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Week of December 03, 2012

Question:

You mentioned last week that MPPR reductions would be made for cardiovascular and ophthalmology? How much of a reduction is planned for next year?

Answer:

For diagnostic ophthalmology services, a 20-percent reduction will apply. For diagnostic cardiovascular services, a 25-percent reduction will apply. For codes affected by the new multiple procedure payment reduction (MPPR), see Tables 10–15 in the in the Medicare physician fee schedule final rule at http://www.gpo.gov/fdsys/pkg/FR-2012-11-15/pdf/2012-26902.pdf.

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Week of November 26, 2012

Question:

Besides the change related to the imaging services provided by multiple physicians that you noted last week, what other changes have been made to the MPPR for next year?

Answer:

For 2013, effective January 1, the Centers for Medicare & Medicaid Services (CMS) will implement two other primary changes related to the multiple procedure payment reduction (MPPR) policy.

  • CMS has added the following to the list of nuclear medicine codes covered by the MPPR policy: CPT code 78306 (bone imaging; whole body) when followed by 78320 (bone imaging; SPECT).
  • The technical component (TC) and TC portion of global services for certain diagnostic cardiovascular and ophthalmology procedures will be reduced when the service is furnished by the same physician (or same physicians in the same group practice) to the same patient in the same session on the same day.

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Week of November 19, 2012

Question:

For 2013, will the imaging services provided by physician groups be included in the multiple procedure payment reduction (MPPR) policy?

Answer:

Yes. In the 2012 final rule, the Centers for Medicare & Medicaid Services finalized the policy to apply the MPPR to the PC and TC of the second and subsequent advanced imaging procedures furnished to the same beneficiary in the same session by a single physician or by multiple physicians in the same group practice. However, due to operational limitations, it did not actually apply the MPPR to services performed by multiple physicians in the same group practice (same national provider identifier [NPI]). However, this will change on and after January 1, 2013, and the MPPR will apply to multiple physicians in same group practice.

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Week of November 12, 2012

Question:

How do we bill when a patient refuses to complete a scan after a radioisotope dose is administered?

Answer:

If the radiopharmaceutical has been administered, you have begun the test. You may code for the test you were planning to do (with modifier 52) as well as the radiopharmaceutical. See a related question and answer on the Society of Nuclear Medicine and Molecular Imaging website at http://interactive.snm.org/index.cfm?PageID=7639.

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Week of November 5, 2012

Question:

Does the following CPT code require image post-processing, and does it need to be three-dimensional?

71275 Computed tomographic angiography [CTA], chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing)

If coronal and sagittal images are reconstructed at the CT scanner workstation and sent with the axial images, does this satisfy the requirements of CPT 71275?

Answer:

All CTA exams, including 71275, require 3D post-processing. Coronal and sagittal reconstructions, even if sent with the axial images, do not constitute 3D.

As noted in the fall 2008 issue of Clinical Examples in Radiology, CTA is a distinct type of service that includes post-processing for angiographic reconstructions. In order to report these, the physician needs to use different techniques that can all broadly be classified as 3D techniques. These include maximum intensity pixel (MIP) reconstruction, volume-rendered images, or other 3D techniques.

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Week of October 29, 2012

Question:

In our hospital, patients occasionally may need to repeat a diagnostic exam such as a computed tomography (CT) or magnetic resonance imaging (MRI). We usually agree that these are not reportable services, but radiologists argue that they should be able to bill a second time because they are generating a second report. Can you provide guidelines about this?

Answer:

Why was the repeat study performed? If the repeat exam is done because the first is sub-optimal technically, then it should not be coded. However, if the patient’s condition changes, or if the second exam is done to follow-up during or after treatment then the second exam can be billed.

The NCCI Policy Manual for Medicare Services (Chapter 9, Section C.1) offers the following guidance about technically inadequate imaging at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.

1. If radiographs have to be repeated in the course of a radiographic encounter due to substandard quality, only one unit of service for the code can be reported. If the radiologist elects to obtain additional views after reviewing initial films in order to render an interpretation, the Medicare policy on the ordering of diagnostic tests must be followed. The CPT code describing the total service should be reported, even if the patient was released from the radiology suite and had to return for additional services. Also, the CPT descriptors for many of these services refer to a "minimum" number of views. If more than the minimum number specified is necessary and no other more specific CPT code is available, only that service should be reported. However, if additional films are necessary due to a change in the patient's condition, separate reporting may be appropriate.

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Week of October 22, 2012

Question:

The documentation requirements for reporting a computed tomography angiography (CTA) study are very clear (3D reconstructions, MIPS or shaded-surface rendering, etc.), but I cannot find guidance anywhere on documentation requirements for magnetic resonance angiographies (MRAs). Are radiologists not required to mention any sort of post-processing in their report? Why?

Answer:

MRAs do not require specific documentation about post-processing. The techniques for MRA are different than those used for CTA, and 2D or 3D imaging sequences can be used.

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Week of October 15, 2012

Question:

If a patient comes in for a two-day whole-body tumor scan with SPECT, we bill 78804 and 78803. If the ordering physician wants SPECT of more than one area, can we charge 78803 more than once?

Answer:

You can bill 78803 only once per session. If SPECT of one area is done on the first day and another medically necessary SPECT is done on day two, you may code 78803 for each day. Remember to document and bill each on the appropriate date of service. More on this can be found in a question and answer on the Society of Nuclear Medicine and Molecular Imaging website at http://interactive.snm.org/index.cfm?PageID=7649.

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Week of October 8, 2012

Question:

Sometimes the radiopharmaceutical is injected for intra-operative use (breast cancer surgery/parathyroid surgery). Is there a special way to code these situations? In these instances, the patient is just being injected and never scanned.

Answer:

You should consider two codes. For the breast cancer surgery, you are probably doing a sentinel node injection. If no images are taken, then the following code is used for the injection: 38792—injection procedure; radioactive tracer for identification of sentinel node. If images are taken, assign instead code 78195—lymphatics and lymph nodes imaging (i.e., not 37892).

In other cases, particularly parathyroid, where you are injecting a radiopharmaceutical and sending the patient to surgery without imaging, assign the following code:

78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (e.g., parathyroid adenoma)

You would also assign the appropriate A-code for the radiopharmaceutical used.

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Week of October 1, 2012

Question:

We purchased a computed tomography (CT) lung computer-aided detection (CAD) system that we use on all of our CT chest scans. We also are looking at a CAD system for CT virtual colonoscopy. Both systems tell us to charge CPT code 76497 since there is no code for CT CAD. Are we allowed to charge for the CAD?

Answer:

In the above cases, assign code 76497 (unlisted CT procedure [e.g., diagnostic, interventional]) for CAD. Your payer may consider it to be non-covered and, therefore, not pay it. It also cannot be separately billed to the patient. However, you should still assign the code to begin gathering data on the procedure..

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Week of September 24, 2012

Question:

If a patient has magnetic resonance imaging (MRI) of the foot and ankle, would 73718 and 73721 be assigned or would it be 73721 x2 with modifier 59?

Answer:

The Spring 2007 Clinical Examples in Radiology included the following answer to this question: If an MRI of the ankle was ordered and the field of view extended to include part of the foot, code only for the ankle (MRI joint – 73721). However, if a new set-up and new coil are used with new parameters for the foot, then it would be appropriate to report two separate exams, 73721 for the ankle and 73718 for the foot.

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Week of September 17, 2012

Question:

Is it appropriate to assign code G0269 if a selective renal angiogram is performed from a right femoral approach and a left external iliac angiogram from a left side puncture and the closure device is placed on the left?

Answer:

We recommend that you closely review the American Medical Association’s CPT Assistant from July and October 2011 as well as the third quarter of the American Hospital Association’s Coding Clinic for HCPCS. These references provide information relative to the assignment of level ll code G0269 with diagnostic and/or therapeutic invasive radiology procedures—specifically, when assigning codes that contain narrative instructions that seem to preclude this. We also recommend that you contact your payer to clarify requirements when contemplating assignment of this code.

When diagnostic peripheral angiography is performed, there are no CPT instructions precluding assignment of G0269 for percutaneous closure-device placement with CPT codes 75710 or 75716.

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Week of September 10, 2012

Question:

Is intravascular ultrasound (IVUS) of the renal artery separately billable with the new codes? Specifically, I was wondering about CPT 37250.

Answer:

CPT 2012 shows no narrative instructions or parenthetical notes before or after the codes for selective diagnostic renal angiography (36251–36254) precluding assignment of IVUS codes (37250–37251, 75945–75946) with CPT options 36251–36254. There also are no national correct coding initiative (CCI) edits.

A potential problem may exist, however, since the parenthetical note following codes 37251 and 75946 indicates the codes that IVUS may be used with, and codes 36251–36254 are not included. Some payers may interpret this to mean that IVUS codes cannot be used with 36251–36254. Verify your payer’s specific coding/billing requirements before submitting these codes together.

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Week of September 03, 2012

Question:

For a patient with a retroperitoneal hemorrhage, the physician selects superior mesenteric artery (SMA), celiac, internal iliac and unilateral renal. The intervention was an embolization of the posterior division of the internal iliac artery. How do I code the renal artery in this case?

Answer:

If diagnostic imaging was done, renal angiogram would be coded as 36251 (unilateral, assuming main renal artery catheterized). If the renal artery was only selectively engaged to perform an intervention (but no diagnostic imaging was performed), assign the appropriate selective catheterization code from the 36245–36247 series instead of 3625x code.

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Week of August 27, 2012

Question:

When an abdominal aortography is performed prior to selective renal angiography and findings reported included abdominal aortic aneurysm or dissection, would it be appropriate to code 75625 in addition to the selective renal code(s)?

Answer:

The renal angiography codes (36251–36254) include “flush aortography.” Since “flush aortography” is not defined, many payers consider any aortography to be included in the renal angiogram. The American Medical Association (AMA) introduced the new renal angiogram codes at the 2011 CPT Symposium and stated that these codes included an aortogram (not “flush,” just “aortogram”).

The national correct coding initiative (CCI) edits bundle 75625 into 36251–36254. The edit may be bypassed by a modifier, but for Medicare at least, that would only be correct if the aortogram was performed at a separate session/encounter on the same date of service.

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Week of August 20, 2012

Question:

Is ultrasonic (US) guidance included in renal angiography? Or can it be coded in addition to these procedures?

Answer:

Per the 2012 CPT manual and the NCCI Policy Manual for Medicare Services, there are no restrictions that state US guidance for vascular access may not be separately coded. Documentation should support medical necessity and CPT criteria must be met before submitting this code (76937) in addition to 3625x.

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Week of August 13, 2012

Question:

What code is correct to report esophageal Doppler monitoring?

Answer:

Between now and September 30, 2012, code 76999—unlisted ultrasound procedure (e.g., diagnostic, interventional—should be assigned. However, effective October 1, the code to report changes to G9157—transesophageal Doppler used for cardiac monitoring. Medicare contractors will deny claim lines containing HCPCS code 76999 on that date.

For all of the details on this, including modifier usage, see transmittal R2472CP (issued May 18) at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2472CP.pdf.

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Week of August 6, 2012

Question:

Angioplasty and stenting are performed in the right common iliac then angioplasty is performed in the right external iliac. Would this be coded as 37220 with 37223?

Answer:

The stent placement is higher in the hierarchy for lower extremity revascularization, so that should be coded as the primary, then angioplasty in the additional vessel would be coded. For the angioplasty with stent in the common iliac, the following code would be assigned:

37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

For the angioplasty in the external iliac, assign this code:

37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

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Week of July 30, 2012

Question:

The accreditation requirement went into effect on January 1, 2012. Is global billing still allowed?

Answer:

According to the Centers for Medicare & Medicaid Services, global billing is still allowed—if you are accredited. If you are not accredited and you submit a global claim for an advanced diagnostic imaging (ADI) service on or after January 1, 2012, the claim will be denied. If you are submitting a claim for the professional component alone on an ADI service, accreditation is not needed.

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Week of July 23, 2012

Question:

Would you agree that when doing an anteroposterior (AP) view of the abdomen with an oblique view that code 74010-52 would be assigned, or would you code 74000 to the lowest specificity?

Answer:

We agree with your decision to use 74010-52—radiologic examination, abdomen; AP and additional oblique and cone views.

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Week of July 16, 2012

Question:

Prior to a PET scan, all patients have a blood glucose level done, which is drawn by a tech or RN from the intravenous (IV) port we insert to administer the FDG radiotracer. This is consistent with the American College of Radiology practice guidelines. If the glucose level is elevated, we cancel the PET and waste the FDG since it has not been given to the patient.

In 2012, modifier 52 was updated to also include "cancellation" of services for which anesthesia is not planned. Can we bill the PET scan CPT with modifier 52? What about the FDG, since the edits will be produced without both a procedure and radiotracer?

Answer:

We would say no, because the FDG was never injected. In the following question and answer on its website, the SNM describes two different scenarios in answer to whether there is an allowed charge for missed or discontinued appointments and radiopharmaceuticals (RPs). In its answers, it says a nuclear medicine study begins when the RP is given to the patient.

  • Scenario: The patient does not show up for the scheduled procedure, and you are left with the cost of the RP. Medicare states that if services are not rendered then you cannot bill. It is the facility's choice to decide to bill the patient directly. For further assistance, see the CMS memo at http://www.cms.org/uploads/MissedAppt.pdf.
  • Scenario: The patient arrives and receives a RP but for some reason does not return, gets ill, becomes claustrophobic, etc. Select the CPT code based on the procedure actually performed. For example, if only one image is obtained, you may choose a limited or single study CPT procedure code. If no imaging is performed, choose the lowest level code in the intended section of CPT and bill with modifier 52 (reduced service) or modifier 53 (discontinued service), if appropriate.

    Remember: CMS states that, for nuclear medicine procedures, you have begun the study if you have administered a RP—because as the administration is an integral part of the procedure code. It is necessary, and may be required, to dictate a detailed report of the administered RP and any imaging and include it with the submitted bill so the payer can determine a payment based on what was performed. You should bill for any purchased and administered RP using the appropriate HCPCS Level II code.

    In some locations, payer systems cannot accommodate modifier 52, and the payer may instruct you to code for RP plus the appropriate administration code.

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Week of July 09, 2012

Question:

Can you please explain how the combination computed tomography (CT) CPT codes work? Are these codes just for Medicare patients?

Answer:

No, they are not just for Medicare patients. Codes 74176, 74177, and 74178 are used any time that you do both a CT abdomen and a CT pelvis at the same session. If both scans are done without IV contrast, assign code 74176. If both scans are done with IV contrast, assign code 74177. All other combinations are coded 74178. This would include both exams done without and with IV contrast, one exam done without contrast and the other with contrast, and one done with contrast and the other done without and with contrast, etc. For 2012 there is a new combination code for CT angiography (CTA) of the abdomen and pelvis (74174) for use when both are performed.

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Week of July 02, 2012

Question:

What code do you recommend for a percutaneous feeding tube (e.g., G-tube) injection when the radiologist only interprets the images and does not perform the injection? This occasionally happens with inpatients when the injection is performed by the clinical service.

Answer:

At best, the radiologist could assign 49465-52, but we would have to ask first if the radiologist’s "interpretation" is medically necessary or if it is a quality assurance (QA) paper trail for the hospital.

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Week of June 25, 2012

Question:

Can a quantity of two be billed for the Sestamibi—one dose at rest and one dose at stress? The Medicare MUE [medically unlikely edit] is 3, so that's no help.

Answer:

Yes, you may code Sestamibi twice if you administer it twice, once for the rest study and once for the stress study. If no SPECT is performed, you also should assign CPT code 78452—myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection. If SPECT is not done, the code is 78454.

Since Sestamibi (A9500) is "per study dose," and you are performing two studies, you may assign A9500 x 2. There may be only one CPT code, but it encompasses multiple studies.

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Week of June 18, 2012

Question:

When a PICC line is inserted and there is an x-ray taken to ensure proper placement, can the x-ray be charged separate from the PICC procedure? Then if adjustments are needed requiring additional images to be taken, can these additional images be charged separately?

Answer:

According to the Centers for Medicare & Medicaid Services, chest films to check placement cannot be separately coded. There are national correct coding initiative (NCCI) edits that prohibit coding 71010 and 71020 with 36569.

In addition, the NCCI Policy Manual for Medicare Services, in both chapters 5 and 9, state the following: When a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. The chest radiologic examination is integral to the procedure, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.

Repositioning based on the “check” x-ray would be considered part of the initial placement and not coded separately.

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Week of June 11, 2012

Question:

Our physicians routinely do breast cyst aspiration code 19000 followed by a breast clip placement for further follow-up. Our Medicare payer keeps denying these claims with code 19499. Code 19295 is not appropriate in this case due to the fact that it is an add-on code to 19102, 19103 and 10022. What is the correct CPT code to use?

Answer:

There is no code specifically for this, so the unlisted 19499 would be the correct code, and payers have the option to pay for it or not.

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Week of June 4, 2012

Question:

What CPT code would be appropriate to use for a magnetic resonance venogram?

Answer:

You would code the appropriate magnetic resonance angiography (MRA) of the body area (such as 70544). (Note that is angiography, not MR arteriography.) As such, the MRA includes imaging of arteries and/or veins.

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Week of May 28, 2012

Question:

Do we use 49440 for a CT-guided gastrostomy tube placement?

Answer:

Code 49440 specifies fluoro guidance. If CT guidance is used instead of fluoro, assign code 49999 (unlisted procedure, abdomen, peritoneum and omentum). You might assign code 77012 in addition to 49999, but your payer may bundle that code into the payment.

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Week of May 21, 2012

Question:

What is the difference between a thoracentesis with insert of tube (32422) and tube thoracostomy (32551)?

Answer:

Code 32422 is used for a more transient procedure where the catheter/tube is removed at the end of the session, while 32551 is used for placement of a tube that is left in for a longer term. The following chart may help with accurate assignment of the pleural drainage codes.

32421 Needle in / needle out (+ modality-specific guidance code)
32422 Catheter in / catheter out (+ modality-specific guidance code)
32551 Catheter in / catheter stays in (+75989)
32550 Catheter tunneled / catheter stays in (+75989)

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Week of May 14, 2012

Question:

Can we code a PICC line removal with code 36589?

Answer:

Codes 36589 and 36590 may be assigned to report removal of a tunneled central venous catheter. However, PICC lines are generally not tunneled. Note that the use of 36589 requires blunt dissection and additional work (i.e., more than just pulling out the PICC line). A parenthetical note under 36590 in the CPT book indicates that 36589 and 36590 may not be coded for removal of non-tunneled catheters.

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Week of May 7, 2012

Question:

If a patient has had a breast malignancy, should all subsequent mammography exams be ordered as diagnostic for the remainder of the patient’s life, or is there a point when the exam can return to a screening exam If so, when?

Answer:

That decision is up to the patient and her treating physician. A woman with a past history of breast cancer can have either screening or diagnostic depending on her particular clinical needs. There is no time frame. The decision for screening or diagnostic should come from the referring physician based on his/her knowledge of the patient. The American College of Radiology believes that all subsequent mammograms should be diagnostic, but the Centers for Medicare & Medicaid Services disagrees. For more on this, see http://www.acr.org/Hidden/Economics/FeaturedCategories/Pubs/coding_source/archives/MayJune2006/
MammographyCodingQADoc6.aspx
.

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Week of April 30, 2012

Question:

Can you explain how payment is made under the MPPR policy?

Answer:

The multiple procedure payment reduction (MPPR) policy applies to certain diagnostic imaging studies when multiple physician services are furnished by the same physician to the same patient in the same session on the same day. The policy affects the professional component (PC), the technical component (TC), and the PC and TC of global services.

For the PC and the TC, full payment is made for the service that yields the highest MPFS payment. For the subsequent services furnished by the same physician to the same patient in the same session on the same day, the following apply:

  • For the PC, payment will be made at 75 percent.
  • For the TC, payment will be made at 50 percent.
  • The individual PC and TC services with the highest payments under the MPFS of globally billed services must be determined in order to calculate the reduction.

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Week of April 23, 2012

Question:

We are looking at doing a magnetic resonance imaging (MRI) arthrogram. We are doing all the scans after the contrast injection. Is the appropriate code for “upper extremity, without contrast”? I ask because the radiologist feels the “with” code is used when the contrast is intravenous not an injection under fluoroscopy. We believe the following codes would be assigned: 77002, 23350, and 73220.

Answer:

For MRI and computed tomography (CT), “with contrast” may be performed via intravenous, intra-articular (for joints), or intrathecal (for spine). Most of the time, the MRI code will be a “with contrast,” not a “with and without contrast.” In the case of your shoulder arthrogram, your codes are correct for the fluoro guidance and injection:

77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
23350 Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography
However, for the MRI, you would assign the following:
73222 MRI (e.g., proton), any joint of upper extremity; with contrast material(s)
If imaging had been done prior to the injection and then after, then the following code would be assigned:
73223 MRI (e.g., proton), any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences

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Week of April 16, 2012

Question:

What is the proper way to bill for Nuclear with myoview and nuclear with lexiscan?

Answer:

We assume you mean a myocardial perfusion scan. If so, there are many variables and not one answer. The code choice or choices depend upon what was ordered, performed, and documented. For the myocardial perfusion scan itself, you can choose one of the following, depending on how the exam is performed: 78451–78454.

In addition, one or more of the “stress test” codes may be assigned: 93015–93018. The facility may also charge for any radiopharmaceutical and non-RP drugs used. Some of the common ones are:
A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose (Cardiolite, Miraluma, Mibi, Sestamibi)
A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose (Myoview, Tetrofosmin, Tetro)
J0152 Injection, adenosine for diagnostic use, 30 mg (Adenoscan)
J1245 Injection, dipyridamole, per 10 mg (Persantine IV)
J1250 Injection, dobutamine hydrochloride, per 250 mg (Dobutrex)
J2785 Injection, regadenoson, 0.1 mg (LexiScan)

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Week of April 9, 2012

Question:

When doing a transcatheter embolization of the head and neck for epistaxis, can 61626 and 75894 be used twice for intervention done on both the left internal maxillary artery branches and then on the right side, or is the entire "head" considered one field? The question applies then to 75898 for follow-up angiography when intervention is done on both sides. We billed only one each for 61626, 75894, and 75898, even though embolization was done of the left and right internal maxillary artery branches.

Answer:

Code 61626 should be assigned only once to identify the two vessels feeding one operative field.

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Week of April 2, 2012

Question:

If a patient is sent for an X-ray with a diagnosis of "injury," what diagnosis code would be assigned?

Answer:

An injury would be coded with a site-specific 959.x code. “Trauma,” however, is not considered necessarily as an injury and would be coded V71.4 in the absence of additional indications or findings. For more information, see the AHA Coding Clinic for ICD-9-CM, 1Q 2006.

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Week of March 26, 2012

Question:

When does the reduction for performing multiple procedures take effect?

Answer:

The multiple procedure payment reduction (MPPR) for the professional component (PC) will be implemented on July 2 with an effective date of January 1. For more on this policy, see http://www.acr.org/HomePageCategories/News/ACRNewsCenter/MPPR-Policy-Applied-to-Professional-Component-in-2012.aspx.

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Week of March 19, 2012

Question:

We've been assigning unlisted code 76497 for a CT cystogram. Is that correct?

Answer:

No, a computed tomography (CT) cystogram is a protocol that can vary from practice to practice but is, usually, a CT pelvis and possibly also a CT abdomen. Your doctor should dictate exactly what was performed, and your code choice would then be clear. See the Q & A in the January/February 2007 ACR Radiology Coding Source for more information.

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Week of March 12, 2012

Question:

We (hospital) use heat-damaged RBC Tc-Ultratag for assessment of accessory spleen. Can I code separately for the Ultratag?

Answer:

Yes, even though Medicare packages the diagnostic radiopharmaceuticals under the hospital outpatient prospective payment system (OPPS), you should still list the code. The code for Ultratag is A9560.

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Week of March 5, 2012

Question:

I believe the answer to your question last week regarding an ultrasound ordered as complete abdomen to include kidneys and bladder is incomplete. The question was this: Is it appropriate to code both 76700 for the complete abdomen and 76857 for the bladder study?

Answer:

If a complete abdominal ultrasound and a bladder ultrasound are both medically necessary, ordered, and performed, then it would be appropriate to code both 76700 and 76857. CPT code 76700 for the abdominal ultrasound does not include imaging of the bladder. Imaging of the bladder is included in a complete retroperitoneal ultrasound (76770) when done for urinary tract pathology.

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February 27, 2012

Question:

If an ultrasound is ordered as complete abdomen to include kidneys and bladder, is it appropriate to code both 76700 for the complete abdomen and 76857 for the bladder study?

Answer:

If a study of the kidneys and bladder is performed, assign code 76700. If only the bladder is evaluated (specific focus on the bladder with a limited study of the pelvis), code 76857 would be appropriate.

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February 20, 2012

Question:

In the issue dated February 6, 2012, you answered a question about the new bundled paracentesis. I have another question. If the radiologist does an ultrasound for the localization and a general surgeon does the actual paracentesis, how should we bill for that now that the code includes guidance?

Answer:

There are varying opinions regarding the situation you describe. In the past, the American College of Radiology (ACR) has said that localizing fluid prior to a paracentesis would be included in the paracentesis and not separately coded. However, that was when the same physician performed the localization ultrasound and the paracentesis AND when guidance was separately coded. Now, it is less clear.

Some say that the radiology department and the radiologist would code 76705 for localizing the ascites, and the surgeon would code 49082 or 49083 (depending on whether he used guidance) for the paracentesis. Others say that localization of known ascites prior to a paracentesis is part of guidance, and not separately coded.  The radiologist would have to get his payment from the general surgeon.  (The hospital would code 49083 for paracentesis with guidance.)

MedLearn has sent a letter to ACR for its opinion on this but has not received a response yet.

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February 13, 2012

Question:

A patient comes to the emergency department (ED) with a history of pain due to a fall, and she is refusing to bear weight. The ED physician orders right femur and right hip x-rays.

AP/lat views are taken of the femur, and AP/lat views are taken of the hip (four views total). Although the two hip views complete the series, a femur must include hip to knee and in an adult both joints are not usually included on a single film.

Normally, we charge the patient for 73550 (femur, two views) and 73510 (hip, complete, minimum two views). But one of our radiologists states that we cannot charge the patient for both exams because "when x-raying a femur, the hip views are included." What is the correct way to charge this patient?

Answer:

If both femur and hip are ordered, and separate exams are performed, then both 73550 and 73510 should be coded.

While the femur is part of the hip, the joint itself encompasses more than just the femur and so evaluation of the hip joint and evaluation of the femur are separate studies.

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February 6, 2012

Question:

If the doctor does an ultrasound prior to paracentesis, can we code the ultrasound?

Answer:

If the ultrasound is diagnostic, and, based on the findings, paracentesis is performed, you can code 76705. However, in most cases, the patient has known ascites with an order for paracentesis, and the ultrasound is done just for localization. That is part of the guidance that is now included in paracentesis code 49083.

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January 30, 2012

Question:

How do we code a nuclear medicine whole body bone scan with SPECT/CT?

Answer:

According to Society of Nuclear Medicine (SNM), code the bone scan (78306) and an unlisted nuclear medicine code (78399) for the fused anatomic localization using the computed tomography (CT) (non-diagnostic study). Do not code the CT.

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January 23, 2012

Question:

I think your Radiology Compliance Question of January 16 has a typo in it.  In the last sentence of the answer shouldn’t the CPT code be 72074 instead of the repeated 72072?

Answer:

No, as stated, “If the patient was so large that he or she needed two films to get one lateral view, then you would code only 72072.” This is still three “views”; it just took four films to get those three views.

If the second lateral view was not a repeat (or second film for one view), but was instead different from the first and gave the physician additional information, then 72074 could be coded.

If the second lateral was taken at a different session from the first (for a medically necessary reason), then assign 72072 for the first session and 72020-59 for the second session.

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January 16, 2012

Question:

A patient was seen for thoracic pain and x-rays of the thoracic spine were ordered: one AP, two Lateral and one swimmer’s view. Would the appropriate CPT code be 72072 (for three views since one view was taken twice) or 72074 since all together there were four views?

Answer:

The answer depends on why the lateral was done twice. If there was a technical problem that required the repeating of the lateral, then 72072 would be coded for the three "usable" views: AP, lateral and swimmer’s.

If the patient was so large that he or she needed two films to get one lateral view, then you would code only 72072.

If the second lateral view was not a repeat (or second film for one view), but was instead different from the first and gave the physician additional information, then 72074 could be coded.

If the second lateral was taken at a different session from the first (for a medically necessary reason), then code 72072 for the first session and 72020-59 for the second session.

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January 9, 2012

Question:

Were any diagnostic RPs removed from the pass-through list for 2012?

Answer:

Per statute, a pass-through period of three years is a maximum, which means that the Centers for Medicare & Medicaid Services cannot grant any extensions. As required, CMS removed the diagnostic RP below from the pass-through list for 2012.

A9582 Iobenguane, I‐123, dx, per study dose, up to 15 millicuries (AdreView™)

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January 2, 2012

Question:

Are there any radiopharmaceuticals with pass-through status?

Answer:

The pass-through list for 2012 includes just one diagnostic RP, and the HCPCS level II code that should be reported for it changed from last year. For 2012, the code below replaces C9406 on the pass-through list, although the code descriptor remains identical.

A9584 - Iodine I‐123 Ioflupane, diagnostic, per study dose, (up to 5 millicuries) (trade name DaTscan™)

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December 26, 2011

Question:

How will radiopharmaceuticals be paid under Medicare next year?

Answer:

Payments for diagnostic radiopharmaceuticals (RPs), contrast agents, and implantable biologics will continue to be packaged with the major procedure payment. However, instead of the proposed $80 per day threshold, CMS finalized the threshold at $75 per day—an increase from the 2011 $70 per day threshold.

As always, average sales price (ASP) will be used to pay for the pass‐through drugs. If ASP is not available, CMS will pay based on wholesale acquisition cost (WAC) plus 6 percent. If WAC is not available, payment is based on 95 percent of the most recently published average wholesale price (AWP).

In 2012, hospitals will continue to receive separate prospective payment for therapeutic RPs at a rate of ASP + 4 percent. CMS determines this rate by using voluntary manufacturer‐submitted information, if available, and considers this rate to be the best proxy for the average acquisition and handling costs of therapeutic RPs. If ASP information is not available, CMS will set payment based upon mean costs from hospital claims data at charges adjusted using department specific cost‐to‐charge ratio.

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December 19, 2011

Question:

During a renal angiogram we saw that the patient had an accessory left renal artery. This artery was subsequently selectively catheterized and imaged. Do we add 36245 for that catheterization?

Answer:

For claims dated before January 1, 2012, that would be correct. However, beginning on January 1, 2012, there are new complete codes for renal angiography, which include all the work of renal angiography, including catheterization and imaging of accessory arteries.

Code 36251 is unilateral, first order—left or right main renal artery and any accessory renal artery(s); 36252 is bilateral first order—both main renal arteries and any accessory renal arteries; 36253 is unilateral second order or higher—left or right renal artery branches (including any accessory arteries); 36254 is bilateral second order or higher—second order or higher branches of both renal arteries (including any accessory arteries). Codes 75722 and 75724 have been deleted, and you would not also code 36245.

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December 12, 2011

Question:

The description of code 73592 includes the word "infant," but I cannot locate the definition for this word in the CPT manual. Is an infant considered 12 months of age or older?

Answer:

An “infant” is considered one-year old or less. Note that some payers are very specific about this, such as 365 days or less, some even less than 365 days. So, a baby born on December 6, 2010, would no longer considered an infant on December 7, 2011, since she would be one year, one day old. At this point, she is considered a “child,” and the definition of child is much less-defined.

For codes 73542 and 76010, which specify “infant or child,” the range can be up to 12, 17, or 18 months, depending on specific payer definitions.

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December 5, 2011

Question:

We have an order for magnetic resonance imaging (MRI) thigh and MRI tibia-fibula on the same patient. Can we use CPT 73718 twice?

Answer:

No: One leg equal one non-joint code. See Clinical Examples in Radiology, Spring 2007.

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November 28, 2011

Question:

Should we code the diagnosis for imaging exams by symptoms or by findings?

Answer:

For outpatient hospitals and physicians, findings appropriate to the reason for the exam are coded if the exam has been interpreted prior to billing. Incidental findings may be coded, but not as the primary diagnosis. If the exam has not been interpreted, or if the interpretation is not available at the time of coding and billing, then the original symptoms or other reason for the exam would be coded.

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November 21, 2011

Question:

What is the status of the 2012 OPPS multiple imaging composite policy?

Answer:

Under the 2012 hospital OPPS, CMS will continue to pay for all multiple imaging procedures within an imaging family performed on the same date of service using the multiple imaging composite payment methodology. The 2012 payment rates for the five multiple imaging composite APCs (8004, 8005, 8006, 8007, and 8008) are based on median costs calculated from the 2010 claims. Table 8 of the final rule lists the HCPCS codes that will be subject to this policy and their respective families and approximate composite APC median costs for 2012.

For the final rule (CMS-1525-FC), go to https://www.cms.gov/hospitaloutpatientpps/hord/list.asp.

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November 14, 2011

Question:

What CPT changes can we expect for nuclear medicine for next year?

Answer:

The nuclear medicine section of the 2012 CPT Book includes changes to imaging codes that address liver, pulmonary, and lung procedures. The American Medical Association deleted codes 78220 and 78223 and added two new codes to align the descriptions with the current standard of practice. Also, there are now four new codes, which replace codes 78584–78596, to report lung imaging, As with the above, the new codes support current standards of practice.

*If you have not done so already, make sure you register for MedLearn's 2012 Nuclear Medicine Coding Update webcast on December 16th. CLICK HERE for more info & registration.

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November 7, 2011

Question:

We are getting denials from almost all commercial insurances on the professional fee side when we bill 73562 and 73560 (with the appropriate LT and RT modifiers assigned) together on one claim. Our claims are returned with a denial on the 73560 stating that it would be considered unbundling for us to bill both codes.

How is that possible? The only thing we can think of is that the commercial insurances aren't on the same page as Medicare, and they don't know about the rules surrounding 73565. When we coded out the 73565 along with a 73562 or a 73560 we never had an issue.

I have two questions: Where can I find the official documentation that states the rules on 73565? Do you think it would help if we submit that literature with our appeal so they see why we are coding the way we are and realize that they're behind the times?

Answer:

If 73560-RT is being denied with 73562-LT, we would suggest using modifier 59 instead of, or before, modifier -RT. Modifier use is non-standard and payer-specific, so we would try modifier 59 as this payer seems to not be recognizing RT and LT.

The rule related to only using 73565 can be found in the fall 2006 issue of Clinical Examples in Radiology, published jointly by the American Medical Association and the American College of Radiology, which can be purchased, if you don’t have it, at https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod850006.

We would certainly recommend appeal, with documentation. The problem you may run into then would be medical necessity for bilateral knees.

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October 31, 2011

Question:

What changes have the AMA made in the CT section of the 2012 codes?

Answer:

In the bone/joint studies section of diagnostic radiology, the AMA deleted and did not replace code 77079 (CT, bone mineral density study, 1 or more sites; appendicular skeleton). However, for CTA of the abdomen and pelvis that is performed during one session, it created the following new code. You may recall that last year the AMA merged CT of the abdomen and pelvis, and many expected CTA also to be merged for 2012.

74174 CTA, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing.

Current codes 72191–72197 and 74175 should continue to be assigned when a CTA of either the abdomen or the pelvis is performed at a separate session.

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October 24, 2011

Question:

I work for a neurosurgeon who assigns code 77003 when he assigns 62301 and 27096. I believe this is incorrect and that this code can only be assigned once per region or session if only one region is done during that session. If two or more regions are done with the same procedural session, then it would be coded two or more times with the appropriate modifiers.

For example, a C-spine with any number of injections would be 77003 x 1. If a C-spine and L-spine are performed during the same session, then 77003 (C-spine) and 77003-59 (L-spine), same session, but two regions would be assigned.

Can you provide guidance about the above?

Answer:

The June 2008 issue of CPT Assistant includes an article on fluoroscopic codes including 77003, and it includes this statement: “To further clarify, code 77003 is intended to be reported per spinal region (not per level).”

In addition, the following can be found in Centers for Medicare & Medicaid Services’ National Correct Coding Initiative Policy Manual, Chapter 9: “CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.”

And one more reference from the SIR Interventional Radiology Coding Guide: “Use 72275 instead of 77003 if formal epidurography is also done. Report 72275 or 77003 ONCE per spinal region.”

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October 17, 2011

Question:

In the update for the 2011 CPT codes, the AMA merged codes for the CT of the abdomen and pelvis. Rumor had it that this would occur for CTA this year. Has it?

Answer:

Yes, there is a new code to use when computed tomography angiography (CTA) of the abdomen and pelvis are performed during one session, and that code is 74174—CTA, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing.

Current codes 72191–72197 and 74175 should continue to be assigned when a CTA of either the abdomen or the pelvis is performed at a separate session.

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October 10, 2011

Question:

Is it necessary for the radiologist to document each view of the X-ray along with the impression of that area. For example, a chest X-ray—posteroanterior (PA)/lateral (LAT) is done, and it is normal. Does the radiologist need to state the PA view of the chest is normal and then the LAT view of the chest is normal?

Answer:

No, that is not necessary. He or she would need to document that AP and LAT views were done, but then can give a general, overall impression. The American College of Radiology documentation guidelines can be found by CLICKING HERE .

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October 3, 2011

Question:

On what type of bill should charges for outpatient physician involvement in the administration of low osmolar contrast medium (LOCM) be submitted by a method II critical access hospital (CAH)?

Answer:

These charges should be submitted on type of bill (TOB) 85X (CAH) with the following included:

  • The appropriate outpatient hospital visit CPT code for evaluation and management (E&M) services; and
  • Revenue code 096X, 097X or 098X (professional fees).

For more on this, see http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM4234.pdf.

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September 26, 2011

Question:

Do the upcoming accreditation requirements apply to the radiologists that interpret the images?

Answer:

No, the accreditation requirements apply only to the suppliers producing the images, not to the physician's interpretation of the image. However, all interpreting physicians must meet the accreditation organizations’ published standards for qualifications and responsibilities of medical directors and supervising physicians, such as training in advanced diagnostic imaging services in a residency program and expertise obtained through experience or continuing medical education courses.

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September 19, 2011

Question:

Does an order for a “nuclear medicine cardiolyte stress test” need to indicate “with treadmill” in order to bill 93015 with 78452?

Answer:

No, the stress test does NOT have to be a treadmill to assign code 93015. It can be pharmacological stressing only. As the code description states, cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress.

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September 12, 2011

Question:

In GU reports, our radiologist has referred to a “double-J.” What is this?

Answer:

Most commonly, a “double-J” or “J-J” stent refers to a device that has been placed into the ureter, through the renal pelvis into the bladder. It can also be placed through the urethra into the bladder, into the ureter and finally into the renal pelvis.

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September 5, 2011

Question:

Recently we had an orthopedic physician order the following CT exams on the same patient for the same date: CT knee LT WO, CT foot LT WO, CT ankle LT WO, CT ext. lower LT WO, and CT leg upper LT WO. Of course, all of these scans use the same CPT code of 73700.
What is the proper way to bill for all of these procedures?

Answer:

CT, unlike magnetic resonance imaging, does not have separate codes for joint and non-joint.  The appropriate code from the 73700–73702 series should be coded once per extremity for any and all areas of that extremity imaged.
 
In the February 2011 and July 2011 issues of CPT Assistant, the American Medical Associationanswered similar questions concerning CT upper extremity.

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August 29, 2011

Question:

I have heard that radiology records are very vulnerable to patient-privacy violations. Is this true, and if so why?

Answer:

First and foremost, it is because the volume of cases reviewed by radiologists is higher than that of other physicians. In addition, radiologists are frequently called to do consults, which necessitate transfer of patient medical information and/or films. Radiology reports often move from the site of service to an outside billing office, which may be located in the hospital or elsewhere. Outside couriers carry records to and from radiology offices.

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August 22, 2011

Question:

Our doctors have changed the way they do stress studies. Initially, they performed them and only if they are positive do they perform resting images. However, the patient doesn't always come back for the resting images in a timely fashion, so there could be a few days in between each study. The question is should we bill 78451 for each date or hold off and bill 78452 for the first date of service? This also happens for patients who are over a certain weight. They have to have a two-day protocol.

Answer:

You must hold the claims to see if they do both studies. If they do both studies within 7 to 10 days (not hard and fast numbers but a ballpark), then bill the multiple-study code (78452 or 78454). If only a single-study is performed, then assign code 78451 or 78453.

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August 15, 2011

Question:

I know that CMS has given permission to use 47550–47556 when the procedures are performed with a percutaneous approach by an interventional radiologist. If we do a percutaneous removal of an internal biliary stent, can we code it as 43269 / 74329, or do we need to use an unlisted code?

Answer:

Code 43269 refers to a retrograde removal of a stent. A percutaneous approach would be antegrade. We would recommend the unlisted code 47999 and 76496.

About the use of endoscopy codes, the Society of Interventional Radiology says the following:

”In the biliary system, the CPT Editorial Panel and [CMS] instructions to use the endoscopy codes (47552–47556) were direct and specific. To this end, radiological supervision and interpretation code cross references were inserted in the AMA CPT manual and a new biliary “endoscopy” code (47556) was also added at the request of the SIR and the ACR. Therefore, the biliary “endoscopy” codes (47552–47556) are to be considered the accurate codes for describing these services whether performed percutaneously or by endoscopic approach.” 

The above is limited to 47552–47556 as being specifically allowed, although in other places they just say “biliary endoscopy” without the limitation. We would be leery of recommending outside that small subset of codes without specific approval from the payer.

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August 8, 2011

Question:

Can CPT codes 75625 and 93567 be assigned together?

Answer:

Both of these codes could be used if two separate procedures were performed, but not routinely one with the other.
For example, if an abdominal aortogram (such as an abdominal aortic aneurysm) was performed with a diagnostic left heart cath (LHC) and coronaries, then codes 93458 and 75625 would be submitted. If a diagnostic LHC and coronaries were performed with an accompanying aortic root or ascending aortogram, then codes 93458 and 93567 would be used.

If a diagnostic LHC and coronaries, abdominal aortogram (such as for abdominal aortic aneurysm) and an aortic root or ascending aortogram were performed, ONLY then would codes 93458, 75625 and 93567 be used.

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August 1, 2011

Question:

If a nerve block procedure (64415, 64417, 64445 or 64450), is performed pre- or post-operative, is it appropriate to bill for the ultrasonic guidance for needle placement (76942) separately?

Answer:

Currently, code 76942 may be coded separately with codes 64415, 64417, 64445 and 64450. CPT does not indicate that imaging guidance is included, and there are currently no CCI edits prohibiting their use together.

 

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July 25, 2011

Question:

Is it necessary for radiologists to document each view of the X-ray along with the impression of that area. For example, a chest X-ray—posteroanterior (PA)/lateral (LAT) —is done, and it is normal. Does the radiologist need to state the PA view of the chest is normal and then the LAT view of the chest is normal?

Answer:

No, that is not necessary. Radiologists do need to document that AP and LAT views were done, but then they can give a general, overall impression. The American College of Radiology documentation guidelines can be found by CLICKING HERE.

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July 18, 2011

Question:

I am the director of oncology services at a regional cancer center, and I have a question about our multidisciplinary clinic. During this clinic, an outpatient will be seen by multiple physician specialists (different private practices) along with one of our nurse practitioners. We would like your guidance on what would be considered appropriate billing for this clinic.

Answer:

In order to report a facility component, the clinics have to be provider-based and have to have developed their own acuity levels—-a set of standard guidelines for coding visits (as opposed to procedures). These standards are different from what the physician uses, and the levels for hospital outpatient and physician billing do not have to match. The hospital standards are likely set up based on resources used, time spent, and staff.

So, for each specialist that the patient visits, you (the hospital) would assign an evaluation and management (E&M) code (99211–99215) based on your internal standards and report that on the UB-04. Use modifier 27 to indicate multiple hospital outpatient visits on the same date of service. If you don’t have those standards, check with the medical records department, which should have a copy.

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July 11, 2011

Question:

What are the proper CPT codes to report cystoscopy with a retrograde pyelogram and cystoscopy with manipulation and retrograde pyelogram?

Answer:

According to the American Medical Association (in a September 2000 CPT Assistant), the most appropriate method to report a cystoscopy with a retrograde pyelogram (RPG) is to assign the following codes:

  • For the cystoscopy, assign code 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service); and
  • For the radiologic portion of the retrograde pyelography, assign 74420 (urography, retrograde, with or without KUB). If the physician is only performing the professional component, then append modifier 26.

If a cystoscopy with manipulation and RPG were performed, you would assign 52330 (cystourethroscopy, including ureteral catheterization; with manipulation, without removal of ureteral calculus) in addition to 52005 and 74420, because 52330 is considered to be a distinct procedure that would be reported separately.

Report the CPT code for the primary procedure if the same provider performs multiple procedures or services at the same session. Appending modifier 51 (multiple procedures) to the additional procedure or service code(s).

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July 4, 2011

Question:

We have a new X-ray machine that takes images from skull to sacrum for scoliosis patients. What is the code for this (a full cervical sacrum)?

Answer:

If the prime reason is for scoliosis, we suggest looking at code 72069.  This is not a great fit, but really covers the reason for the exam.  If not using this, one could also make an argument for 72010-52 or unlisted procedure code (UPC) 76499.

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June 27, 2011

Question:

Can you please tell me how the following procedure should be billed? Whole-body imaging was performed on January 20 and 21 (images done at 4 and 24 hours). SPECT imaging was done only on January 21. Should this be reported as 78804 on January 21 and 78803 on January 21?

Answer:

When two whole-body studies are performed on two separate days, the correct code is 78804—radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring 2 or more days imaging. Also assign code 78803—radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT).

 

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June 20, 2011

Question:

Our doctors have changed the way they do stress studies. Initially, they performed them and only for positives do they perform resting images. However, the patient doesn't always come back for the resting images in a timely fashion, so there could be a few days in between each study. Should we bill 78451 for each date or hold off and bill 78452 for the first date of service? This also happens for patients who are over a certain weight. They have to have a two-day protocol.

Answer:

You must hold the claims to see if they do both studies. If they do both studies within 7 to 10 days (not hard and fast numbers but a ballpark), then bill the multiple study code (78452 or 78454). If only a single-study is performed then assign code 78451 or 78453.

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June 13, 2011

Question:

Whole-body imaging was performed on January 10 and 11 (images done at 4 and 24 hours). SPECT imaging also was performed on both dates. Should this be reported as 78804 on January 11 and 78803 for both January 10 and 11?

Answer:

At http://interactive.snm.org/index.cfm?PageID=7649, the Society of Nuclear Medicine (SNM) suggests that billing two units for code 78803 is appropriate. However, note that historically the American College of Radiology (ACR) has questioned the billing of the second SPECT on a separate date.

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June 6, 2011

Question:

Is fluoroscopy covered under the new accreditation requirement?

Answer:

The accreditation requirement excludes X-ray, ultrasound, and fluoroscopy procedures. The law also excludes diagnostic and screening mammography, which are subject to quality oversight by the Food and Drug Administration under the Mammography Quality Standards Act.

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May 30, 2011

Question:

Is the new registry for NaF-PET available yet?

Answer:

In February, 2011, the National Oncologic PET Registry (NOPR) announced the completion of its second registry—this one for sodium fluoride F-18 bone positron emission tomography imaging (NaF-PET). The NOPR developed this registry in response to the February 10, 2010, national coverage determination (NCD) issued by the Centers for Medicare & Medicaid Services for NaF-PET scans used to identify bone metastasis.

For more on this registry, see the following transmittals:

http://www.cms.gov/Transmittals/downloads/R119NCD.pdf
http://www.cms.gov/Transmittals/downloads/R1937CP.pdf
http://www.cms.gov/Transmittals/downloads/R2096CP.pdf

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May 23, 2011

Question:

I am trying to find out if Sinografin® 380mg/ml is high osmolar or low osmolar contrast. Can you help?

Answer:

It is a high osmolar contrast material (HOCM) that is coded with Q9963—HOCM, 350–399 mg/ml iodine concentration, per ml. Medicare does not pay for HOCM, but other payers may.

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May 16, 2011

Question:

If we are doing a digital screening mammogram for one breast, G0202, should we use a modifier 52?

Answer:

Yes. Since there is no unilateral screening mammogram code, you use the appropriate screening code (G0202 for digital or 77057 for film) with modifier 52.

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May 9, 2011

Question:

I know that there are new CPT codes for CT abdomen and pelvis this year and that previously used codes 74150–74170 and 72192–72194 still exist. However, I am not sure when they should be used. Can you help?

Answer:

Codes 74150–74170 and 72192–72194 do still exist, but they will be used when only the abdomen or only the pelvis is imaged. When both the abdomen and pelvis are imaged, you must use one of the new combination CT abdomen and pelvis codes:

• Use 74176 when both the abdomen and pelvis are imaged without contrast.
• Use 74177 when both are imaged with contrast.
• Code 74178 will be used most often because it is used for all other combinations: abdomen with contrast and pelvis without contrast, pelvis with contrast and abdomen without contrast, abdomen with contrast and without contrast, pelvis with contrast and without contrast, etc.

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May 2, 2011

Question:

CPT code 78223 (hepatobiliary ductal imaging) does not contain SPECT imaging in the definition. In a specific study we performed, a hepatobiliary study was ordered and performed. The interpreting physician felt a SPECT was needed after viewing the first hour of images. How would the SPECT portion be coded since it is not included in 78223?

Answer:

Since a specific code does not exist for hepatobiliary SPECT imaging, a single unit of one of the following code options could be submitted:

78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine

Or

78223 Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function

Some may say that CPT 78803 would be appropriate, but we do not recommend it as code 78223 clearly describes the planar study done.

The Instructions for Use of the CPT Codebook clearly states the following: “Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.”

We would not recommend submitting both the planar and SPECT imaging codes based upon existing information from the Centers for Medicare & Medicaid Services stating that SPECT imaging codes would not be submitted in addition to planar codes unless the planar study was whole body imaging.

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April 25, 2011

Question:

I am confused about assigning both a CPT code and an ICD-9 code when a patient comes in with an order from her physician for a screening mammogram, but she has breast implants. Can we still use code 77057 or G0202 if she has implants? Does it matter if the implants are cosmetic or from prior breast cancer surgery? What is the correct ICD-9 coding if there are no problems and no history of breast cancer? At one time, I thought screening codes could not be used for women with implants.

Answer:

The decision for screening or diagnostic mammogram lies with the patient and her doctor. Having implants (for any reason) does not automatically make a mammogram diagnostic. You can still code 77057 or G0202. Your diagnosis would still be V76.12 (or V76.11 if the patient had history of breast cancer). If you choose, you could add diagnosis code V43.82 to indicate implants, but it would be a secondary code and would not change the primary diagnosis or CPT code. If the implants are because of previous breast cancer and mastectomy, then the patient and her doctor can decide to order a diagnostic mammogram, but if they order a screening test, that is what you must do.

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April 18, 2011

Question:

How would you code the following x-ray exam: bilateral standing, including both right and left knees in one shot, lateral left knee, bilateral sunrise view, including both right and left knees in 1 shot?

Answer:

You would code 73560-RT and 73562-LT. Code 73565 can be coded only if it is the only exam done. When additional views are done with the standing AP bilateral, you count the views for each knee and code the appropriate codes by number of views.

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April 11, 2011

Question:

Is it appropriate to code both a whole body scan and a SPECT of the neck during the same encounter? Codes 78802 and 78803 do not appear to be editing out together.

Answer:

It is appropriate to bill 78802 and 78803 together. If the initial study was less than whole body (78800 or 78801) and SPECT, then you would only code the SPECT (78803).

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April 4, 2011

Question:

How does OPPS payment differ for non-pass-through and pass-through radiopharmaceuticals?

Answer:

For 2011, payment for the acquisition cost and associated pharmacy overhead costs for non-pass-through drugs, biologicals and therapeutic RPs is made at a single rate of average sales price (ASP) plus 5 percent. Pass-through items receive a single payment of ASP plus 6 percent, which also includes acquisition and pharmacy overhead costs.

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March 28, 2011

Question:

CPT code 78596 has the "/" symbol which to me denotes “and/or.” Am I corrrect to assume then that to do just a perfusion or just a ventilation quantitive study, we can code 78596? If not, what should we code?

Answer:

No, both ventilation and perfusion are required for this code, which is used primarily to determine how a patient would fare if either a part or the whole lung was removed. If only ventilation or only perfusion is performed, we recommend 78599 be used. Code 78596 should not be used with the imaging lung scan codes (78580-78588).

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March 21, 2011

Question:

How is angioplasty of the tibial/peroneal trunk (TPT) and the anterior tibial (AT) artery coded?

Answer:

In the winter 2011 issue of Clinical Examples in Radiology Newsletter (volume 7, issue 1, page 4), the American Medical Association provided the following guideline. (Also see “note” below if you have purchased MedLearn’s 2011 Instructional Coding Guide for Lower Extremity Interventions.)

“The common tibial-peroneal trunk is considered to be part of the tibial-peroneal territory, and is not considered a separate fourth vessel for CPT reporting purposes. For instance, if lesions in the common tibial-peroneal trunk are treated in conjunction with lesions in the posterior-tibial artery, a single code would be reported. If, however, the anterior tibial artery and the common tibial-peroneal trunk are treated, it is appropriate to report a primary and an add-on code, as the anterior-tibial artery is not a vessel that rises from the tibial-peroneal trunk.”

Therefore, per these clarifying instructions, when both the AT and common TPT are treated at the same session by angioplasty, it would be appropriate to assign both the primary procedure code (37228) and the each additional vessel code (37232).

Note: This new AMA guidance replaces the answer we provided in question 4, page 46, of our 2011 Instructional Coding Guide for Lower Extremity Interventions. Please delete the answer we provided, which was appropriate at the time of publication, and follow the above guideline.

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March 14, 2011

Question:

I heard that the FDA recently approved a new radiopharmaceutical. Is this true? Where can I find information on it?

Answer:

Yes, the Food and Drug Administration approved DaTscan™ (ioflupane I 123 injection) for visualization of dopamine transporters in patients with suspected parkinsonian syndromes. It is the diagnostic imaging agent approved to assist physicians in the evaluation of neurodegenerative movement disorders and aids in differentiating parkinsonian syndromes from essential tremor. See GE Healthcare website for more: http://us.datscan.com/

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March 7, 2011

Question:

Were the new lower extremity revascularization codes intended for use on the venous procedures when performing the multiple procedures? For every one of the new codes in the 2011 CPT book, the AMA states “arteries” but not “venous” procedures.

Answer:

You are correct. The 2011 CPT changes pertain to codes 37220–37235, which are all arterial procedures, not venous studies.

For venous procedures, angioplasty continues to be component coded as in the past. Specifically, non-selective or selective catheter/device placement is assigned supervision and interpretation (S&I) code 75978 and open or percutaneous surgical code of 35460 or 35476.

Percutaneous or open stent placement is still defined by S&I code 75960 and open or percutaneous surgical codes ranging from 37205–37208. As stated above, non-selective or selective catheter/device placement is also separately coded.

Atherectomy would never be coded for a venous procedure as by definition, an atherectomy is only performed on an artery.

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February 28, 2011

Question:

Does the sequence in which lower extremity interventions are performed have any bearing on the code assigned?

Answer:

No the sequence in which interventions are performed has no bearing on the code assigned. However, understanding the coding hierarchy is critical to appropriate charging and billing. The hierarchy, from highest-valued to lowest-valued procedure is as follows:

1. Atherectomy and stent with or without angioplasty;

2. Atherectomy with or without angioplasty;

3. Stent with or without angioplasty; and

4. Angioplasty only.

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February 21, 2011

Question:

My question is a follow-up to the answer to the February 7 question about the new specialty code 95. Where does this code go? I have read that it should be added to a paper application or in PECOS, but I cannot find it anywhere on the 855B. The CMS memos are out there but they don’t tell us what to do with the code. Can you help?

Answer:

Unfortunately, the guidelines coming from the Centers for Medicare & Medicaid Services are not comprehensive, but here is what we have “heard.” On either April 1 or July 1, providers who are accredited may assign specialty code 95. The delay is because there is not enough space on the paper claim for this code. We haven’t heard whether this also is the case for the electronic version.

Once CMS decides upon the effective date, providers will put specialty code 95 in the same location on the claim where they now designate their specialties (e.g., IDTF, radiologist, cardiologist, etc.). Note, again, that only if you have accreditation will you assign specialty code 95 in addition to your specialty. We will keep you informed when CMS issues more definite guidelines.

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February 14, 2011

Question:

I am having trouble determining how to code for lower extremity interventions. Can you provide guidance?

Answer:

In January 2011, the coding of lower extremity interventions changed significantly. New codes (37220–37235) within the surgical section of the CPT manual as well as Category III codes (0234T–0238T) describe endovascular revascularization services performed for arterial occlusive disease. These new options describe both open and percutaneous procedures. They are progressive in nature, which means that the more intensive services are inclusive of lesser intensive services. Therefore, the code that includes the most intensive services is reported for the service provided.

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February 7, 2011

Question:

Do you have any information about CMS modifier 95 coming into effect soon, and what it is used for?

Answer:

In Transmittal 2079 (change request 7175, effective April 1, 2011), the Centers for Medicare & Medicaid Services (CMS) identified specialty code 95 (previously used for competitive acquisition program drugs) for advanced diagnostic imaging (ADI) accreditation. This would be similar to the specialty code 69 currently used by independent diagnostic testing facilities (IDTFs). It is not a modifier.

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January 31, 2011

Question:

For 2011, the AMA bundled several codes assigned for the lower extremity interventional procedures. Is this a trend? Does the association plan to continue along this path?

Answer:

As you point out, providers must now assign a complete procedure code instead of code components. For example, before the January 2011 CPT changes, both an angioplasty and the stent procedure would be coded if an angioplasty was performed within the popliteal artery and the angiogram following the angioplasty indicated residual stenosis of greater than 40 percent necessitating a stent for improved long-term outcome. In 2011, only the most intensive service—the stent placement—would be coded. This is because of the new hierarchy in which stent placement includes the angioplasty in the same vessel whether or not it is performed.

In transmittal R2129CP, CMS stated that it expects this bundling to continue over the next several years “as the AMA RUC [relative value scale update committee] further recognizes the work efficiencies for services commonly furnished together.”

The agency goes on to say, “Stakeholders should expect that increased bundling of services into fewer codes will generally result in reduced PFS payment for a comprehensive service by explicitly considering the efficiencies in work and/or PE that may occur when component services are furnished together.”

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January 24, 2011

Question:

We had a case where carbon dioxide was used as a contrast agent during an abdominal aortogram. The patient had renal insufficiency. Is there a code that we can use to capture the use of carbon dioxide?”

Answer:

The only possible code that we know of for the CO2 would be A9698 (non-radioactive contrast imaging material, not otherwise classified, per study). Report this with revenue code 0636.

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January 17, 2011

Question:

Historically, we could report the imaging of the IMA with a heart cath whether the IMA was used as a graft or native. With the inception of the new codes 93455, 93457, 93459, and 93461, is that still true?

Answer:

If a bundled/collapsed code exists for the graft injection with other services, it cannot be fragmented out into a separate charge. If only the grafts are imaged without coronaries, we believe the best code to assign is 93455-52.