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Radiology Compliance Question of the Week

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August 30, 2010

Question:

Is it correct to assign a code for the vertebral biopsy if a vertebroplasty is done on the same vertebrae and thru the same trocar?

Answer:

According to Medicare's current national correct coding initiative (CCI) edits, the biopsy is included in the vertebroplasty and is not coded or billed separately.

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August 23, 2010

Question:

Is it appropriate to code CPT 71275 (CTA chest with contrast) and CPT 71260 (CT thorax with contrast) when they are performed at the same session and there are two separate reports? There are new CCI edits for CT and CTA performed on the same date, as well as for MRI/MRA. Is it appropriate to bill both codes, CT and CTA or MRI and MRA, adding modifier 59?

Answer:

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August 16, 2010

Question:

Our physician completed a femoral angiography with an attempted PTA of the SFA. The physician made several attempts to pass several different wires. The physician also tried to pass a frontrunner catheter (a catheter used for total occlusions) but was not able to pass the lesion. No balloon was used. The patient was on the table for about an hour. Can we bill 35474 with modifier 74?

Answer:

It would be appropriate to charge 35474-74 and 75962, according to CMS transmittal R442CP (http://www.cms.gov/Transmittals/downloads/R442CP.pdf). This memo indicates that the procedure planned should be billed with modifier 74, which indicates that the procedure was terminated at the physician's discretion due to extenuating circumstances.

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August 9, 2010

Question:

I am getting a denial for using CPT codes 78205 and 78215 together. But the CPT book doesn't say that I cannot use them together. Can you help?

Answer:

There are two things going on here

: • There are CCI edits prohibiting the coding of 78205 and 78215 together, and a modifier will not bypass the edit.

• SPECT imaging includes limited area planar imaging.

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August 2, 2010

Question:

What would you code if only a PTA of the AV arterial anastomosis is performed?

Answer:

Report codes 35475 and 75962.

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July 26, 2010

Question:

Our radiologist requests the following: 75557, 75565, 71550, and 71555 when doing cardiac magnetic resonance imaging (MRI) procedures. But we get denials stating we are ordering duplicate exams. Can you shed some light on this?

Answer:

Codes 71550 and 71555 are not cardiac. Code 71550 is for a chest MRI and 71555 is for a MRA. So, unless there is a specific order from the referring physician and medical necessity for non-cardiac chest MRI and MRA along with the cardiac, the radiologist shouldn't be assigning those two codes.

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July 19, 2010

Question:

When I have an order for knee, three views (73562) and also for anteroposterior (AP) standing bilateral (73565), I get rejections. Should this be billed as is with a modifier 59, or should the exams be combined for billing purposes into knee 4+ views (73564)? The same question applies when knee, three views bilateral with AP standing bilateral are performed.

Answer:

Code 73565 should be billed when it is the only exam done. When the AP standing view is done with other views, then assign the appropriate code according to the number of views. If you do AP standing bilateral along with three additional views of the right knee, you would assign 73564-RT and 73560-LT.

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July 12, 2010

Question:

We perform top of the skull to mid thigh as well as a head/neck image but only charge for 78815. Why can't we charge for each additional view? Some patients are on the table for 30 minutes, others two hours.

Answer:

Generally, when the American Medical Association (AMA) Relative Update Committee (RUC) creates and values new CPT codes, it does so on the basis of a typical study (including additional views). Providers should choose the appropriate code to reflect the body area imaged. Even if the brain is included in an extended "skull base to mid thigh" study, the code for brain imaging should not be used in addition to CPT 78812 or 78815, according to the SNM at http://interactive.snm.org/index.cfm?PageID=5408&RPID=1995.

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July 5, 2010

Question:

Does anyone bill ultrasound guidance with a trigger point 20553? If so, can 76942 be billed more than once per session if multiple areas are used, or should it be one 76942 per session?

Answer:

Code 76942 can be billed with 20553, but we would only assign the code once. Code 20553 can only be assigned once, so the guidance would follow the same (in our opinion). Also, according to NCCI policy, code 76942 can only be coded once per session.

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June 28, 2010

Question:

Is it appropriate to code CPT 71275 (CTA chest with contrast) and CPT 71260 (CT thorax with contrast) when performed at the same session, when there are two separate reports? There are new CCI edits for CT and CTA performed on the same date, as well as for MRI/MRA. Is it appropriate to bill both codes, CT & CTA or MRI & MRA, adding modifier 59?

Answer:

It would be appropriate if there is medical necessity to perform both studies and the physician's dictated report indicates why each study was performed and what information was gleaned from it that would benefit the referring physician in the management of the patient. Within the CTA report, ensure there is documentation to support post-processing of images. If this is not said, the documentation may not support a CTA.

Additionally, information from the American College of Radiology (ACR) states that it believes that a CT of the chest and a CTA of the chest would be infrequent (ACR Coding Source, July 2003). Therefore, we recommend that the facility obtain two orders with medical necessity to support both codes and that separate acquisition of data be performed.

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June 21, 2010

Question:

We do planar and SPECT parathyroid nuclear imaging. Can we bill for 78070 and 78803?

Answer:

SNM recommends that you code only 78803 when both planar and SPECT or only SPECT is performed. See http://interactive.snm.org/index.cfm?PageID=2442&RPID=1995.

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June 14, 2010

Question:

Can we use modifier 59 on 62311 (single lumbar, sacral injection) with 72275 (epidurography, radiological supervision and interpretation)?

Answer:

If a full and complete epidurogram is performed in addition to the epidural injection, modifier 59 can be assigned to code 62311. Be sure that the documentation supports a full and complete study (i.e., epidurography performed, images obtained, and findings documented).

Here's an excerpt from our Interventional Radiology Coder: "If epidurography is performed, submit code 72275. This code inherently includes fluoroscopy so codes 76000, 76001, 77002 or 77003 should not be charged in addition to code 72275. Use code 72275 only if a true contrast study is performed, which also includes recording of this procedure plus a traditional, specific radiologic report. If only the ESI injection is done, use code 77003 or 77012."

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June 7, 2010

Question:

Can we use modifier 59 with 77002 (fluoroscopic guidance for needle placement) when doing the procedure marked 20610 (arthocentesis, aspiration and/or injection; major joint or bursa)?

Answer:

There is currently no national correct coding initiative (CCI) edit preventing these two codes from being reported together. Ensure that the documentation within the physician's dictated report indicates the use of fluoroscopic guidance.

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May 31, 2010

Question:

We received a physician's order for screening of one breast and a diagnostic mammogram of the other. Should we assign codes 77057-52-LT and 77055-RT, or should we bill the whole exam as diagnostic and assign code 77056?

Answer:

We recommend that you code it as a bilateral breast exam and assign 77056. You also should go back to the ordering physician for a corrected diagnosis, and he/she should order one service, which is a bilateral diagnostic mammogram.

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May 24, 2010

Question:

Would one of the following codes be right for this scenario for a hospital outpatient? The patient comes in (ED or outpatient facilities) for a chest, two views, PA/lateral: 71020. Same visit immediately following but additional single PA view with nipple markers performed: 71035 (special view) or 71010 (single view chest). Would any modifier be appropriate if 71010?

Answer:

Code 71035 is the correct choice.

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May 17, 2010

Question:

Our question relates to CPT code 78472. We understand from our compliance team that certain documentation is required by the interpreting physician if a patient study is being performed for initial or follow-up chemotherapy. Can you please provide the type of documentation so we can review and understand its intent? I think this is being driven by Medicare.

Answer:

Your doctor needs to document when during the treatment the exam is taking place. You should then check your local coverage determination (LCD) and coding articles for the appropriate diagnoses to use. For example, a Medicare payer in Ohio instructed its providers to report the following codes:

- V72.85 when the test is performed as a baseline study before chemotherapy;
- V58.83 for subsequent monitoring while the patient is receiving chemotherapy; and
- V67.2 for testing when chemotherapy is completed.

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May 10, 2010

Question:

We get OCE edit 0040 if we try to bill 25607 and 76000 together. Also, the Complete Global Service Data for Orthopaedic Surgery, Volume 1 states, under CPT 25607, includes: intraoperative supervision and positioning of imaging and or monitoring equipment by operating surgeon or assistants.

Answer:

There is an edit in place that prohibits the reporting of code 76000 with code 25607. We recommend that modifier 59 not be assigned to code 76000.

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May 3, 2010

Question:

I was wondering if you could help me with something. We are currently using a product called Redicat Barium Sulfate Suspension in our hospital radiology department. Does this particular item have a HCPCS code associated with it?

Answer:

Barium products such as Readi-Cat do not have a HCPCS code because they are valued into the base procedure.

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April 26, 2010

Question:

Is it appropriate to code CPT 71275, CTA chest with contrast and CPT 71260, CT thorax with contrast, when performed at the same session, when there are two separate reports? There are new CCI edits for CT and CTA performed on the same date, as well as for MRI/MRA. Is it appropriate to bill both codes, CT & CTA or MRI & MRA, adding modifier 59?

Answer:

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April 19, 2010

Question:

What is the correct CPT code for CT mandible?

Answer:

Codes 70486, 70487 and 70488 would be your choices.

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April 12, 2010

Question:

Can you please provide a source for the answer you gave in the February 1 radiology question? I have provided that question and answer below for reference:

Question: In a hospital setting, if the doctor's order does not state contrast for CT and MRI, is the radiologist allowed to choose the protocol for the exam? Or do we need an order stating with or without contrast?

Answer: In any setting if the referring physician's order does not state contrast, then radiologists are allowed to make this decision. In the hospital, even if the order does state contrast usage, radiologists can change it if they can document medical necessity for the change (although it's still good for them to discuss with the referring physicians).

Answer:

The ordering rules for diagnostic tests can be found in the online Medicare Benefit Policy Manual, chapter 15, section 80.6 at http://www.cms.gov/manuals/Downloads/bp102c15.pdf. Be sure to check especially section 80.6.4 in Chapter 15.

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April 5, 2010

Question:

What codes would be assigned for nonionic contrast exclusively?

Answer:

The following codes may be assigned:

Q9965 LOCM 100-199mg/ml iodine, 1 ml
Q9966 LOCM 200-299mg/ml iodine, 1 ml
Q9967 LOCM 300-399mg/ml iodine, 1 ml

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March 29, 2010

Question:

The following relates to a physician's office setting. A patient who has had a positive pregnancy test comes in and is having bleeding. An ultrasound was performed, and no fetal pole or sac was found. The physician calls it a spontaneous AB. Would we code it OB or not?

Answer:

It would be an OB ultrasound. Both the American Medical Association (AMA) and the American College of Radiology (ACR) have published articles stating the following. If a pelvic ultrasound is ordered on a woman who has had a positive pregnancy test and who has symptoms that could be pregnancy-related, code the exam as a pregnancy ultrasound even if she is found to no longer be pregnant or the problem is something outside of pregnancy such as appendicitis.

Conversely, if the patient has not been determined to be pregnant (no pregnancy test) but a pelvic ultrasound shows she is pregnant, assign a code for a non-pregnancy study. (See CPT Assistant, October 2001.)

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March 22, 2010

Question:

Does the reporting of 78452 require that the radiologist state SPECT in the dictation, or can he or she state that gated emission tomographic reconstruction was obtained?

Answer:

We always recommend that the interpreting physician provide as much specificity with his/her dictated report as possible. From a technical perspective, one would understand that "gated emission tomographic reconstruction" represents a SPECT study. However, we cannot ensure that an external auditor would recognize a SPECT study was performed. To avoid conflict and delay in reimbursement, we would recommend that the physician indicate the procedure was performed by SPECT technique.

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March 15, 2010

Question:

How should we code a bubble study?

Answer:

There is no separate code allowed for the injection of agitated saline, and saline is not considered a contrast. Report the study with CPT 93306 or 93307 as applicable. Do not assign CPT 93352.

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March 8, 2010

Question:

What are the appropriate codes to use for a peritoneal lymphocele drainage and lymphocele ablation by sclerosing done with imaging guidance?

Answer:

In the 2010 CPT Manual, the American Medical Association included a parenthetical note under 49323 (surgical laparoscopy; with drainage of lymphocele to peritoneal cavity) indicating that 49061 can be consulted for percutaneous drainage. So, we recommend using the appropriate drainage code for the body area for the location of the lymphocele plus the modality-specific image-guidance code. As for sclerosing, assign an unlisted code for the anatomic area treated.

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March 1, 2010

Question:

When placing an IVC filter, is it still appropriate to charge separately for the inferior vena cavagram? One of our radiologists reported that the SIR made a statement that the IVC should be considered a component of the IVC filter placement and that it should not be coded separately. Perhaps that is true for the professional component?

Answer:

Medicare has issued a national correct coding initiative (NCCI) edit that prohibits the reporting of code 75825 with code 75940. Medicare considers code 75825 as a component of code 75940. The rationale behind this is that the Centers for Medicare &
Medicaid Services (CMS) understand that the cavagram is primarily used to locate the position of the renal veins and is a roadmap rather then a diagnostic study. Modifier 59 could be assigned if the cavagram demonstrated findings that warranted a medical intervention prior to the deployment of the filter.

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February 22, 2010

Question:

Last week's question related to 3D reconstruction. Can you provide information about archiving 3D reconstruction images? Have we always been required to archive 3D images? The sagittal and coronal reformats don't seem to be an issue, as they have always been archived. But this 3D is of concern for correct billing as far back as '06.

Answer:

Here's what the American College of Radiology (ACR) has to say in ACR Coding Source (May/June 2009):

Q: Is it necessary to have a permanent archive of 3D images acquired on a CTA study?

A. Yes, the ACR believes that it is necessary to have a permanent archive of 3D images acquired on a CTA study. The axial data set from which 3D images are created is insufficient for the reporting of a CTA study. When reformatted images are acquired and interpreted in addition to the CT axial images, the reformatted images are a part of the study and should be permanently archived. Just as it is required that a permanent hardcopy image be maintained for a plain film study, permanent CTA reformatted images should be permanently archived.

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February 15, 2010

Question:

Can we charge a CTA for chest when the report is dictated as 2D reconstructions, or does it have to say 3D in order for it to be a CTA?

Answer:

CTA requires 3D reconstructions. If only 2D is reported, then a code for CT instead of CTA must be assigned.

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February 8, 2010

Question:

I am unable to find any guidelines as to when a "limited" (52) modifier would be appropriate for TEE exams (93312-93318). Would the following be eligible for the limited modifier?

Here's the scenario: Code 93312 was the exam planned. Patient was prepped in a room, placed under conscious sedation with nurse supervising, attending and rad tech in room; H&P and pre-procedure assessment done; IV placed; throat is sprayed.

Due to patient anxiety, or other medical reason, the probe cannot be placed down the throat after several attempts, and the exam is terminated. No images are taken as probe was never placed in throat.

Answer:

Because the patient received moderate sedation, modifier 74 would be assigned to code 93312. The reference for the use of modifier 74 is transmittal 442 at http://www.cms.hhs.gov/Transmittals/downloads/R442CP.pdf.

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February 1, 2010

Question:

Do we consider CT post discogram as with contrast? The CPT manual guidance indicates that the term "with contrast" would qualify for intravascular, intra-articular and intrathecal, but it does not specifically mention intradisc space. Can intradisc be considered as intra-articular space to qualify for with contrast?

Answer:

According to the American College of Radiology, "CT post-discogram is a CT without contrast. Intradiscal is not the same as intrathecal, and does not qualify as "with contrast."

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January 25, 2010

Question:

Our facility performs a two-view chest x-ray to identify pleural effusion, and then the patient has an ultrasound-guided thoracentesis and a follow-up, one-view chest x-ray. The CCI edit indicates that 71010 is a component of 71020. Since these two procedures are performed several hours apart, would a modifier 59 be appropriate (separate session) or must we delete the 71010?

Answer:

If signs and symptoms (for example, shortness of breath, chest pain or discomfort) were present that warranted the chest x-ray, modifier 59 would be appropriate. For example, if this is routine protocol for all thoracentesis procedures, we would recommend that the chest x-ray charge be included within the thoracentesis procedure.

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January 18, 2010

Question:

Our neurosurgeon is performing in the IR suite a trigeminal balloon gangliolysis under general anesthesia to treat trigeminal neuralgia. Under fluoroscopic guidance, a needle is guided through the cheek into the foramen ovale then a balloon is inserted and inflated to compress the trigeminal nerve ganglion. I am considering use of codes 64610 and 77002 for the hospital coding setting. Is this correct?

Answer:

According to the American Medical Association, there is not a specific CPT code that accurately describes PRF. [What's PRF?] Therefore, the unlisted procedure code 64999 (for the nervous system) should be reported. It also should be noted that it is not appropriate to report codes 64600-64681 (destruction by neurolytic agent) for this procedure.

Be sure to submit supporting documentation (such as a procedure report) with your claim. The AMA says that the documentation must include an "adequate" description of the nature, extent, and need for the procedure as well as the time, effort, and equipment necessary to provide it.

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January 11, 2010

Question:

Has the 21.2 percent reduction for physician payment taken effect yet?

Answer:

No. Via the Department of Defense Appropriations Act of 2010, Congress temporarily canceled the reduction by mandating that no update (that is, zero percent) be applied for the two-month period of January 1 through February 28, 2010. President Obama signed the legislation to make it official.

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January 4, 2010

Question:

Can you tell me what the global period for an arthrogram would be? Also, where do I find the list of global periods for all radiology procedures?

Answer:

Each of the arthrogram injection codes have a global period of 000, which is defined as follows: Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.

The Medicare physician fee schedule relative value file includes the global period for every CPT code. Note that this file is changed on a quarterly basis, if not more often, so be sure you check back to see whether the new files contain any pertinent code changes. You can find the file at http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp?sortByDID=1a&submit=Go&filterType=none&filterByDID=-99&sortOrder=ascending&intNumPerPage=10.

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December 28, 2009

Question:

Our outpatient facility has many patients that have radiation treatment planning (CPT 77014) done. Medicare has this listed as a status N or packaged into other services done on the same day. Our problem is that many times this is the only service done on a date of service. Do you have any billing or appeal advice on getting reimbursement for this service?

We are at the point of having to write off this service, which is usually a CT scan to set treatment locations. We feel we are coding this correctly as CPT 77014.

Answer:

Code 77014 (CT for placement of radiation therapy fields) has been packaged under the hospital outpatient PPS for a couple of years. Per CMS this and other image guidance codes (77417, 76950 and 77421) are packaged into the primary procedure and, as a result, are not reimbursed separately.

The process of care in the initial planning stage includes the simulation of the patient using CPT codes 77280, 77285 or 77290, depending on the complexity of the procedure. In the scenario you note, the CT is performed for the data acquisition.
Simulation is the process of defining relevant normal and abnormal anatomy and acquiring the images and data necessary to develop the patient's approved radiation treatment plan.

Based on the above guidance from CMS and ASTRO/ACR guidance, the actual procedure you are performing is a simulation using the CT as a means to gather the data for the treatment plan. The billing/reporting of the codes would be as follows:

Day 1:
77261-77263-physician clinical treatment plan - professional only

Day 2:
77280, 77285, 77290-simulation
77014-CT for placement of radiation therapy fields
77334-immobilization device (if used)

Day 3: Treatment planning (Isodose plans, etc.) calculations

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December 21, 2009

Question:

Our diagnostic department does the fluoro-guided needle placement injection 77002 and injects, for example, the hip joint (20610). Then the patient is taken to MRI to have an athrogram performed. Is it proper for us to charge for the fluoro injection and 20610 and to charge for the MRI as well?

Answer:

We recommend you assign codes 77002 and 27093 and then 73722 for the lower extremity joint with contrast MRI.

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December 14, 2009

Question:

What code(s) would you recommend for a gonadal venography?

Answer:

The Society for Interventional Radiology (SIR) says that for left gonadal veins, code 36012 and 75831 should be assigned since the left gonadal vein is typically a branch of the left renal vein. On the right side, the vein usually arises directly from the IVC, so assign code 36011. For the S & I, it recommends 75822 if assessing female pelvic congestion syndrome.

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December 7, 2009

Question:

I'd like to follow up on your response to the October 12 question regarding vein sampling. You stated that the combination of 36500 and 75893 should be charged/coded for each organ sampled. Does this mean that if both kidneys are sampled, the codes would be used twice, with modifiers? And would that be a 50 or a 59 modifier?

Answer:

Yes, if both kidneys were sampled, then 36500, 75893 would be coded twice: 36500-50 and 75893 x 2 would be best, but modifier requirements vary by payer.

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November 30, 2009

Question:

Recently we added digital mammography with CAD at our facility. All images are put through CAD, but the radiologist does not always report CAD on the dictation. Can we charge for the CAD without it being in the dictation since every patient's images are sent through?

Answer:

Current coding guidelines are that if it was not written, it was not done. We would encourage that the radiologist indicate the use of CAD in his/her report so in the event of an external audit the charge can be justified by written word.

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November 16, 2009

Question:

It was recently brought to our attention that CMS stated that effective January 1, 2009, imaging guidance is limited to once per patient per encounter, not dependent on number of biopsies, needles, aspirations. Can you clarify the intent of this? Is this true for bilateral also?

Answer:

At this time, guidance can be coded and billed multiple times if the lesions are separate and distinct. For example, if a biopsy was performed of two lesions--one at the 2 o'clock position and another at the 7 o'clock position, two biopsies would be billed along with two guidance procedures.

Due to the medically unlikely edits (MUEs) and current Medicare guidelines, only one imaging guidance can be reported. (See excerpt below.) This does not limit the number of biopsy procedures codes you can bill.

Below is a useful excerpt from the National Correct Coding Policy Manual for Medicare Services, version 14.3 (hospital) and version 15.0 (physician), Chapter 9--Radiology.

3. 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.

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November 9, 2009

Question:

I work in a hospital-based outpatient services area. When we do a CTA head (CPT code 70496), our department protocol is also to perform a noncontrast head CT (CPT 70490). Currently, we only have a physician's order for a CTA head with clinical to support this test. It appears that the CPT code descriptor for 70496 may also include any noncontrast studies performed as a component of the CTA study. Could you clarify whether it is proper to charge for both 70496 and 70490 as a part of the same encounter?

Answer:

First problem is that code 70490 does not describe CT head but CT, soft tissue of neck. CTA includes any CT images of the same body area. So, it is inappropriate to code 70496 and 70450 (CT head).

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November 2, 2009

Question:

During orthopedic surgical procedures, when a c-arm is utilized and spot images are submitted for interpretation, can we bill for both the fluoro guidance and the images taken?

Answer:

If films were taken off of the fluoro unit (i.e., played back) then one method of charging or the other should be used, but not both, as this would be double-coding. That is, you could charge for fluoro or plain film radiographs, but not both. If clear documentation existed stating the use of fluoro for one part of the exam, and then separate plain films taken in addition to the fluoro, then it would be correct to charge for each. As always, verify modifier assignment against the correct / current version of CCI edits applicable to hospital / physician billing.

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October 26, 2009

Question:

I believe the code listed for last week's question is incorrect. I do not believe code 36426 is correct. Can you check this?

Answer:

Unfortunately, we did give the incorrect code of 36246 for the answer. The right answer is 36247. For clarification, we have reprinted the answer below and apologize for the error:

Catheter/device placement coding is assigned based upon the most distal placement performed, whether it was the diagnostic imaging catheter or the interventional device. Assuming a contralateral approach (for the scenario posed), code 36247 should be assigned.

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October 19, 2009

Question:

A physician places a balloon catheter at the popliteal artery and inflates it but does not dictate that an angiogram was performed with the catheter at that position. Can we code it as catheter tip placement, or can we only code the catheter tip placement as the position of the last angiogram?

Answer:

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October 12, 2009

Question:

I code for radiologists, and I have a doctor that performed sampling of the renal and adrenal veins. I want to confirm whether or not we charge the sampling with 36500/75893 or if we also charge the 36011/36012 with 75833 and 75842? I have seen conflicting information on this-and wasn't sure how to proceed.

Answer:

When performing organ sampling, only codes 75893 and 36500 are to be submitted. No separate codes for either catheter placement (e.g., 36010-36102) or imaging (75xxx series) should be reported. Remember that codes 75893 and 36500 are submitted for each organ sampled, not for each sample acquired.

According to current current correct coding initiative (CCI) edits and information issued by the Society of Interventional Radiology (SIR), codes 36500 and 75893 include the venography and catheter placements. The SIR states the following:

The NCCI edits exclude billing for a selective venous catheterization access code when using 36500. Therefore, 36011 should no longer be billed for selective renins, with or without venography. The procedural code for renal vein renin sampling (36500) should be used for each organ selected, but is not used for nonselective sampling from the IVC. The RS/IS&I code for venous sampling (75893) is likewise used for each selective organ sampled and includes venography. Code 36500 is not coded multiple times when multiple samples are obtained from the same organ through the same access site. When separate and distinct samples from separate and distinct access sites are obtained, code 36500 per from separate and distinct access site.

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October 5, 2009

Question:

There is a rumor going around our hospital that if you perform a CT-guided biopsy and the patient develops a pneumothorax, the charges and supplies associated with the insertion of a chest tube should not be charged. Are you aware of any new rulings on this?

Answer:

Those who believe that those services cannot be billed are getting it from the National Correct Coding Initiative Policy Manual, Chapter 1, Section C 13, which is provided below. They interpret the underlined sentence below to mean that since this was during the procedure and did not require a return to operating room at a later date, this cannot be billed.

I disagree with that interpretation. Treatment of a pneumothorax is NOT usual and necessary; it may be necessary but it is not normal or usual.

13. Treatment of complications of primary surgical procedures is separately reportable with some limitations. The global surgical package for an operative procedure includes all intra-operative services that are normally a usual and necessary part of the procedure. Additionally the global surgical package includes all medical and surgical services required of the surgeon during the postoperative period of the surgery to treat complications that do not require return to the operating room. Thus, treatment of a complication of a primary surgical procedure is not separately reportable (1) if it represents usual and necessary care in the operating room during the procedure or (2) if it occurs postoperatively and does not require return to the operating room. For example, control of hemorrhage is a usual and necessary component of a surgical procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is also not separately reportable unless the patient must be returned to the operating room for treatment. In the latter case, the control of hemorrhage may be separately reportable with modifier -78.

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September 28, 2009

Question:

The GI physicians perform ERCPs at our hospital. We capture several images during the procedure. Our radiologist then interprets these images.

What codes are correct for radiology? Our radiologists want to use 74330 (supervision and interpretation of ERCP) with the 52 modifier (reduced services). Coders in medical records think we should use fluoro code 76000 and an abdomen, one view (74000); they say using 74330 is double-dipping because the radiologist did not perform the procedure. The GI physician is going to code for the actual performance of the ERCP. Any advice will be greatly appreciated.

Answer:

Hospitals should bill 74330 (or other appropriate code) with a code from the 43260-43272 range, as appropriate. This is the recommendation because the hospital is providing all the equipment, staff and overhead. No modifier is required since there would be physician supervision.

For the radiologist asked to review the films and provide a report, assign 74330 (or 74328, 74329 - whichever is most appropriate) with modifier 52.

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September 21, 2009

Question:

We are a physician's group that is affiliated with a hospital. Should we use modifier 26 when billing for a patient who received a hip x-ray under CPT 73510, if the patient is an in-patient at a skilled nursing facility, AND we own the equipment?

Answer:

Yes, modifier 26 would be assigned for the interpretation when a physician group owns the equipment and also obtains and interprets the films obtained. The technical component would have to be billed to the skilled nursing facility (SNF) so that it could bill Medicare under the consolidated billing policy.

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September 14, 2009

Question:

Can fluoro be billed when used during pain-management injections? What about the epidurography done at the same time as the injection? Are the drugs billed separately, or are they included in the procedure?

Answer:

Fluoroscopic guidance for pain management injections is assigned code 77003. However, a full and complete epidurography that is ordered and performed (and coded) includes fluoro, so fluoro would not be separately coded. Epidurography is not billable when an injection is utilized for localization of the needle within the epidural space. More often than not, though, a true diagnostic epidurogram is not done but only a small injection of contrast to verify needle placement. If that is the case, the epidurogram code (72275) is not assigned but fluoro guidance is (77003).

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September 7, 2009

Question:

When coding for computer-aided detection (CAD) for mammography, can we charge additional fees for spot compression/magnification views when the patient returns on a different date for the additional views? Code 77057 would be the original screening mammo charge, and 77052 for CAD. Then on return for additional views, 77055 for mammo charge and 77051 for CAD charge.

Answer:

It would be appropriate to code the CAD with the additional views. We would recommend that the dictating physician indicate in his/her report why the CAD was required and what information was gleaned from it. Even though all the above elements may be met there is no guarantee that a payer will reimburse for CAD every time it is used.

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August 31, 2009

Question:

My physicians are in a heated battle over this question with one of them demanding that I change the standard coding practice set up prior to my coming on board.

At present our rib series is two obliques and a PA chest (71101). We are in the process of modifying this series to include a two-view chest. To ensure that radiologists are properly compensated, we would like (at the request of one of the radiologists) to create a composite study to reflect this. One of the physicians wants a chest to look for effusions. I believe the proper codes should be two-view chest (71020) and two-view ribs (71100). What do you say?

Answer:

Based on the information provided, we agree that codes 71100 and 71020 would be appropriate, assuming that the chest x-ray is taken with AP and lateral views and that there are two separate reports.

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August 24, 2009

Question:

What is the correct way to report kyphoplasty done on one thoracic level and one lumbar level at the same session? Do we report one thoracic level 22523 and one lumbar level 22524, along with 72291 twice for the radiology S&I charge? Or should it be reported with 22523 for thoracic for the first level and 22525 for the additional level, regardless of which vertebral bode is treated second?

Answer:

You would code 22523, 22524, and 72291 x 2. Code 22525 is only assigned when there are two thoracic or two lumbar. For instance, if T12, L1 and L2 are treated, then 22523, 22524, 22525 (72291 x 3) are coded.

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August 17, 2009

Question:

Could you help with the following? Water-soluble contrast was injected though gastrostomy tube followed by a portable AP X-ray of the abdomen.

Answer:

Assign code 49465 for the injection of the contrast through a previously placed tube. This is the only code to report because it includes imaging.

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August 10, 2009

Question:

On June 8, you posted a question and answer about radioactive seed localization breast biopsy. I have an additional question about this topic.

What code is appropriate when the radioactive seed is NOT for treatment purposes but for diagnostic marking of a lesion? The seed was only left in for a short time and then removed in an open biopsy. It is being used in place of wire marking for a breast biopsy.

Answer:

Because it is not a therapeutic procedure but rather a localization procedure, the radiation therapy codes (77776-77778) we cited in our June 8 answer would not be appropriate. Code 76965 also would not be appropriate because the procedure does not relate to therapy.

This limits our choices because there is not a specific code for the placement of the seeds. Nonetheless, we would recommend code 76942 for ultrasound guidance. Please make sure the seeds are "radioactive." It seems that this is an unusual use of seeds due to the dangers posed by radiation exposure.

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August 3, 2009

Question:

Currently, our nursing unit implants PICC lines. They do not use fluoroscopic guidance to implant these, but order a one-view chest x-ray afterwards to check PICC line placement. We have always charged 71010 to check PICC line placement. Is this appropriate?

Answer:

The chest x-ray must be ordered and interpreted by a physician in order to be billed. There is an edit if both 71010 and 77001 are billed for final PICC line position.

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July 27, 2009

Question:

Can we charge for a single view chest x-ray (CPT 71010) to confirm bedside trach placement?

Answer:

If guidance was used for the placement, a chest image might be considered bundled. However, it is likely the chest x-ray would be allowed.

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July 20, 2009

Question:

When a patient has a fem-pop venous bypass graft and the surgeon does an angioplasty in the bypass graft, is it considered an arterial or venous angioplasty?

Answer:

The angioplasty is considered an arterial plasty because the graft is taking the place of the native artery.

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July 13, 2009

Question:

If planar and SPECT imaging of an organ system with one isotope injection occurs at the same time, can you bill for both or is the planar imaging considered part of the SPECT?

Answer:

SPECT and whole body planar can be coded together in only a few instances: bone, tumor, abscess. Other than that, no planar imaging may be charged with a SPECT nuclear medicine service.

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July 6, 2009

Question:

What are the appropriate charges to report for a CT sialography?

Answer:

The following codes would be appropriate:

42550 Injection procedure for sialography
70486 Computed tomography, maxillofacial area; without contrast material

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June 29, 2009

Question:

At our Children's Hospital, the goal, as always, is to minimize radiation exposure to our patients. When a physician orders a CT of the chest and both shoulders, our tech will scan the patient's chest but will include the shoulders and then do a reconstruction of the shoulders from the chest scan. What can we charge?

Answer:

If it is a 2D reconstruction of the extremities that is being performed, the tech side shouldn't be able to bill those, so it would be CT chest only.

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June 22, 2009

Question:

Going back to last week's question, why wouldn't the G-tube exchange code (49450) be used instead of G-J tube exchange with modifier 52 (49452)?

Answer:

We recommended code 49452 as the patient initially had a G-J tube in place. As this tube extends farther into the digestive system, we feel that the procedure is best defined as being coded based upon both where the tip of the initial tube terminated (jejunum) and where it was subsequently advanced (gastric). As such, we feel the modified code (49452-52) better reflects the services rendered as opposed to a code for a G-tube exchange.

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June 15, 2009

Question:

Is it appropriate to charge 49450 (G tube exchange) and 49446 ( convert g to G-J) when the G-J tube is replaced and the J portion is in the stomach and not in the small bowel?

Answer:

Assuming the intention was to replace a G-J tube with another G-J tube, we would not assign either of the codes you have listed. The initial tube was a G-J tube (what they started with), so they didn't convert (49446), nor did they exchange a G-tube (49450). We recommend coding 49452, and probably with modifier -52."

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June 8, 2009

Question:

Our facility is considering providing the new procedure of radioactive seed localization breast Bx. I have located some literature, but at this point other than CPT code 76965 for ultrasound guidance, I am not finding any coding guidance. Can you help?

Answer:

For the interstitial placement of the radioactive seeds, refer to CPT codes 77776-77778.

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June 1, 2009

Question:

My question relates to a physician's order for an abdomen ultrasound. Our radiology department can now perform duplex scan at the same time as diagnostic ultrasound. Radiology has started charging for CPT 76700 and 93976. We have a complete radiology report for CPT 76700, and the body of the report mentions "the patency of portal vein" for CPT 93976. On our Medicare patients, we are getting OCE edit 40 (code is a component of comprehensive procedure). Are we allowed to add modifier 59 to 76700? Do we need an order stating duplex scan of abdomen?

Answer:

Medicare issued this edit many years ago. The edit is to simply indicate that the color Doppler, in many hospitals departments, is a matter of protocol and is not always supported by medical necessity. According to the American College of Radiology (ACR), modifier 59 is applicable when there is medical necessity to perform the color flow in addition to the ultrasound of the abdomen. The ACR goes on to say that within the physician's dictated report the physician should identify why the color Doppler was performed and what information was gleaned from it.

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May 25, 2009

Question:

Can we bill for each nodule in a thyroid that a fine needle aspiration is done upon (e.g., two nodules on the right and one nodule on the left)? Would we bill 76942 x 3 (2 for the right & 1 for the left) and 10022 x 3 (for the other component)?

Answer:

Here is the recommendation from the June/July 2008 issue of ACR Coding Source® :

"Q: Regarding thyroid fine needle aspiration procedures, when more than one nodule in separate lobes are aspirated, is it appropriate to report the fine needle aspiration code multiple times?

A: Several aspiration biopsies of the SAME lesion should only be reported once. When ultrasound guidance is performed, these services are reported using CPT codes 10022 (Fine needle aspiration, with image guidance) and 76942 (Ultrasound guidance for needle placement, imaging supervision and interpretation). However, because these codes were not intended to reflect the work involved in two or more separate lesions (e.g., right and left thyroid lobes), it is appropriate to report the thyroid aspiration codes once per lesion when lesions in different lobes are aspirated. Similarly when core biopsies are obtained in both lobes, it is appropriate to report code 60100 (Biopsy, thyroid, percutaneous core needle) rather than 10022, for each lesion. Please keep in mind that a modifier may be needed to indicate to the payer that distinct and separated lesions were biopsied."

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May 18, 2009

Question:

There has been much discussion on how to code a unilateral mammogram. Many are saying that modifier 52 should be appended to the bilateral screening code. Is this correct?

Answer:

In our consulting practice, we have not seen consistent guidelines on this even among the Medicare payers. Therefore, the best advice seems to be that providers should consult their payers. If a unilateral screening mammography is performed, modifier 52 is correct. However, some payers do not accept this modifier with CPT code 77057. Again, consult with your individual third-party payer for the appropriateness of assigning it.

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May 11, 2009

Question:

My question relates to the answer you gave to the May 4 question regarding procedures ordered for a treatment facility or stand-alone imaging center. You said that a new order would be required. I thought CMS issued a transmittal within the last year stating that a new order wasn't required for the radiologist to decide about contrast vs. non-contrast. Please comment.

Answer:

The topic of whether, under the Medicare program, radiologists may make decisions independent of the physician's order continues to be a point of confusion. We will review the answer to the May 4 radiology question and make appropriate changes this week.

To address your question about a transmittal, the Centers for Medicare & Medicaid Services did issue Transmittal 80 on January 11, 2008 (http://www.cms.hhs.gov/transmittals/downloads/R80BP.pdf), which includes the requirements for ordering and following orders for diagnostic tests performed in a non-hospital testing facility. CMS specifies that interpreting physicians (e.g., radiologists) may proceed without a second order WHEN certain criteria apply. (See Section 80.6.3 in the transmittal attachment.)

According to the American College of Radiology (ACR), the criteria would be met when the treating physician fails to specify the use of contrast in the order, and radiologists are allowed to change the test design according to CMS guidelines. In Transmittal 80, CMS states, "Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media)."

The ACR also says that if the order does specify the use of contrast, then the radiologist must contact the referring physician to discuss the best use of contrast for the test. This is because the radiologist may not know the true intent of the order.

In November 2001, the ACR issued a bulletin on the above topic and summarized a clarification it received from CMS. To access that bulletin, click here.

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May 4, 2009

Question:

We had a hospital outpatient whose physician ordered a CT with contrast of the abdomen. The lab tests revealed that the patient should not have contrast. Can the radiologist make the determination to do the test without contrast, or must the ordering physician be contacted and a new order written?

What about the same scenario as above except the ordering physician orders a CT but does not state with or without contrast. Can the radiologist make the determination to do the tests with or without contrast?

Answer:

In the case of a hospital-based procedure, the use of contrast is at the radiologist's discretion as is the thickness of the slice used in the scan, according to the American College of Radiology. Radiologists may change the design of the test in the hospital setting as well as in a treatment facility or stand-alone imaging center. (See our May 11 radiology question and answer for more.) The only difference between the two is, if the study is being performed in a treatment facility or stand-alone imaging center, the radiologist is allowed to change the design only if the treating physician didn't specify the parameter of the exam, (e.g., didn't specify the use of contrast).

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April 27, 2009

Question:

What CPT/HCPCS would be appropriate for the hospital to bill when magnetic resonance cholangiopancreatography (MRCP) is provided? I do not think that temporary code S8037 can be reported for hospital outpatient services. Is there an alternate code that the hospital can bill?

Answer:

S-codes are specifically NOT for Medicare use. Whether other third-party payers will accept these codes depends on each individual payer and hospitals will need to investigate with their payers before submitting.

Other recommended codes for this procedure can be found in the CPT code series for magnetic resonance imaging of the abdomen (74181-74183). If true 3D post-processing is performed and documented correctly in the dictated report, codes from the 76376-76377 also may be reported.

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April 20, 2009

Question:

Where can I find the new NCD related to PET?

Answer:

In early April, the Centers for Medicare & Medicaid Services (CMS) announced its decision to expand coverage of positron emission tomography (PET) for the initial diagnosis and treatment of Medicare beneficiaries with most solid tumor cancers. It also expanded coverage of PET scans for follow-up testing in beneficiaries who have cervical or ovarian cancer or who are being treated for myeloma. For most solid tumor cancers, National Oncologic PET Registry (NOPR) data collection will no longer be required when the PET scan is used to support initial treatment (or diagnosis and "staging"). (Note that NOPR data is still required for monitoring response to treatment.]

For the CMS decision on FDG-PET for solid tumors (CAG-00181R), go to http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=218.

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April 13, 2009

Question:

When a physician orders an x-ray of the left and right wrists, should Radiology charge 73110RT and 73110LT with a unit of one each on a separate line of a claim? Or should we charge 7311050 with a unit of one?

Answer:

Most Medicare payers require extremity radiographs to be reported with modifiers LT and RT, especially hospital payers. Therefore, you should report 73110RT and 73110LT, and report each with a unit of one and each on a separate claim line.

Modifier 50 is usually associated with reporting bilateral surgical procedures, but not always. If your payer requires modifier 50 for radiographic exams, then bill 7311050 with a unit of one on one line item of the claim form. Verify these requirements with your payer.

Also, Transmittal R442CP states the following: A bilateral procedure is reported on one line using modifier 50. Modifier 50 applies to any bilateral procedure performed on both sides at the same session.

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April 6, 2009

Question:

Would you consider it appropriate to add modifier 59 (different site, different date of service, different procedure) if the procedures identified by codes 25607 and 76000 were performed in the operating room at the same time/site? We believe this modifier would not be appropriate, but the codes will not pass our Medicare edits.

Answer:

The current version (effective April 1) of the national correct coding initiative (CCI) edits indicate that fluoroscopy is inherent in the procedure code 25607 and would not be billed separately. The CCI states that a modifier may be used with these codes.