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Radiology Compliance Question of the Week


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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:

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:

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.