Radiology Coding - AHIMA

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Radiology CodingAudio Seminar/WebinarJuly 17, 2007Practical Tools for Seminar Learning Copyright 2007 American Health Information Management Association. All rights reserved.

DisclaimerThe American Health Information Management Association makes norepresentation or guarantee with respect to the contents herein andspecifically disclaims any implied guarantee of suitability for any specificpurpose. AHIMA has no liability or responsibility to any person or entitywith respect to any loss or damage caused by the use of this audioseminar, including but not limited to any loss of revenue, interruption ofservice, loss of business, or indirect damages resulting from the use of thisprogram. AHIMA makes no guarantee that the use of this program willprevent differences of opinion or disputes with Medicare or other thirdparty payers as to the amount that will be paid to providers of service.CPT five digit codes, nomenclature, and other data are copyright 2006American Medical Association. All Rights Reserved. No fee schedules,basic units, relative values or related listings are included in CPT. The AMAassumes no liability for the data contained herein.As a provider of continuing education, the American Health InformationManagement Association (AHIMA) must assure balance, independence,objectivity and scientific rigor in all of its endeavors. AHIMA is solelyresponsible for control of program objectives and content and the selectionof presenters. All speakers and planning committee members are expectedto disclose to the audience: (1) any significant financial interest or otherrelationships with the manufacturer(s) or provider(s) of any commercialproduct(s) or services(s) discussed in an educational presentation; (2) anysignificant financial interest or other relationship with any companiesproviding commercial support for the activity; and (3) if the presentationwill include discussion of investigational or unlabeled uses of a product.The intent of this requirement is not to prevent a speaker with commercialaffiliations from presenting, but rather to provide the participants withinformation from which they may make their own judgments.AHIMA 2007 Audio Seminar Seriesi

FacultyStacie L. Buck, RHIA, CCS-P, LHRM, RCCMs. Buck has served in several different roles during her 14-year career in healthinformation management including as a medical records coordinator, medical coder, arevenue analyst, an internal auditor, corporate compliance officer, and consultant. Sheis currently Vice President and Managing Partner of Southeast Radiology Managementin Stuart, Florida.She is on the editorial advisory board for the HCPro newsletters MammographyRegulation Report, Radiology Administrator’s Compliance Insider, Health Care AuditingStrategies and she is a frequent contributor to Strategies for Health Care Complianceand to Compliance Monitor Q & A’s Ask the Expert. In addition, she is the author ofthe recently released Radiology Technologist’s Coding Compliance Handbook and is aContributing Editor for The Radiology Manager’s Handbook: Tools & Best Practices forBusiness Success. Stacie also is an audioconference presenter for HCPro, the CodingInstitute and the American Health Information Management Association (AHIMA).An adjunct instructor and advisory board member for the health informationmanagement program at Indian River Community College in Florida, Stacie also servesin the AHIMA Mentoring program. Recently she was the recipient of several awardsincluding the 2005 AHIMA Rising Star Award, FHIMA Outstanding Professional Award &FHIMA Literary Award.Stacie is a current member of the American Health Information ManagementAssociation (AHIMA), the Florida Health Information Management Association (FHIMA)and the Suncoast Health Information Management Association (SHIMA). She serves onthe AHIMA Physician Practice Council and is President of the Florida Health InformationManagement Association.Stacie graduated Magna Cum Laude from Florida International University with aBachelor of Science degree in Health Information Management after earning anAssociate of Arts degree in Business Administration.AHIMA 2007 Audio Seminar Seriesii

Table of ContentsDisclaimer . iFaculty .iiObjectives . 1CPT Guidelines. 1Supervision and Interpretation . 2CMS Guidelines . 3Contrast Materials . 3Coding and Documentation . 4Report DocumentationScreening Mammography. 5Diagnostic Mammography. 6Diagnostic vs. Screening Mammography. 6High Risk V codes . 73D Rendering . 7PET and CT78811-78813 .1078814-78816 .10Coding Questions .11US Documentation GuidelinesCPT .14Abdomen.15Retroperitoneum .16Abdominal and Retroperitoneal.17Pelvic vs. Retroperitoneal.17Transabdominal .18Transabdominal vs Transvaginal .18OB vs. Pelvic.19OB vs. Abdominal.20OB – 76815 .20OB – 76816 .21Ultrasound Guidance .21US w/US Guidance .22US Guidance – Vascular Access .23Duplex Scans .23Coding Guidelines.25Signs and Symptoms or a Diagnosis.26No Reason for Test.27Code Signs/Symptoms .27Coding FAQs“Pecking” Order for Dx Coding.28Common Radiology Modifiers-26 and –TC .29-50 and -52 .30-53 .31-50 .32-76 and -77 .33-GG, -GA, -GY and –CZ .34Florida Whistleblower Case .36Why the Confusion .3742 CFR 410.32 .38Common Questions .40AHIMA 2007 Audio Seminar Series

Table of ContentsTest Orders in the Hospital Setting .43ACR Guidelines for Communication .43References and Resources .44Audience QuestionsAppendix.48CE Certificate InstructionsAHIMA 2007 Audio Seminar Series

Radiology CodingNotes/Comments/QuestionsObjectives Review ICD-9-CM Diagnostic and CPTcoding guidelines for radiology servicesincluding X-Ray, Ultrasound, CT, MRI, PET,Nuclear Medicine, and Mammography.Discuss modifier usage, contrast media,supervision and interpretation.Review documentation requirements foraccurate code assignment and for MedicalNecessity/ABN.1CPT Guidelines CPT-Specific Guidelines Carefully review the guidelines at thebeginning of each section in CPT Know and adhere to the subsection - andcode-specific guidelines anddocumentation requirements. Utilize CPT Assistant references whenavailable/applicable. Clinical Examples in Radiology – AMA/ACR2AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved1

Radiology CodingNotes/Comments/QuestionsCPT Guidelines Written report, signed by the interpretingphysician should be considered an integralpart of a radiologic procedure orinterpretation.When a procedure is performed by 2physicians, the radiologic portion of theprocedure is designated as “RS&I” If physician performs both procedureand RS&I use surgical codes in addition.3Supervision andInterpretationRadiological supervision andinterpretation (RS&I) codes requirejust that – both supervision andinterpretation by the radiologist If either supervision or interpretationis not performed, append a modifier 52 to the RS&I code 4AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved2

Radiology CodingNotes/Comments/QuestionsCMS Guidelines –NCD and LCDAlthough the Medicare Manuals maynot specifically address elementsrequired for a report, don’t forgetthere may be specific NCD or LCDdocumentation requirements! Locate and review all applicablecoverage determinations. 5Contrast Materials “With contrast"refers to contrastadministered: Intravascularly Intra-articularly Intrathecally6AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved3

Radiology CodingNotes/Comments/QuestionsContrast Materials Injection of IV contrast is part of the "withcontrast" - CT, CTA, MRI, and MRAprocedures. For intra-articular injection, use theappropriate joint injection code. For spine examinations "with contrast" intrathecal or intravascular injection. For intrathecal injection, use also 61055 or62284. Oral and/or rectal contrast administrationalone does not qualify as a study "withcontrast."7Contrast Coding and DocumentationRoute of administration Type Concentration Amount Injecting the material is “bundled”,however the appropriate HCPCS codeshould be assigned for the contrast.8AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved4

Radiology CodingNotes/Comments/QuestionsReport DocumentationNumber and types of views Amount, type and route for contrast Separate interpretations for eachexam performed Don’t forget to check your LCDs! Medical necessity Documentation requirements9Screening Mammography 77057 Performed on asymptomatic femalesthat have not manifested any clinicalsigns, symptoms, or physical findings ofbreast cancer. CC & MLO views are obtained of eachbreast.10AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved5

Radiology CodingNotes/Comments/QuestionsDiagnostic Mammography 77055 & 77056 Also called problem-solving mammography orconsultative mammography Performed because there is a reasonable suspicion thatan abnormality may exist Clinical signs, symptoms, or physical findingssuggestive of breast cancer An abnormal or questionable screening mammogram A personal history of breast cancer A personal history of biopsy-proven benign breastdisease. A woman is asymptomatic, but based on her historyand other factors the physician feels diagnostic isappropriate11 Additional views performedDiagnostic vs.Screening Mammogram ACR Coding Source, May/June 2006Implants ACR: Asymptomatic, diagnostic; Symptomatic,diagnostic CMS: Asymptomatic, screening; Symptomatic,diagnosticHistory of biopsy-proven benign disease ACR: Diagnostic CMS: Diagnostic or screening as determined byreferring physicianHistory of mastectomy ACR: Diagnostic (life-long) CMS: May revert to a screening as determined by12the referring physicianAHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved6

Radiology CodingNotes/Comments/QuestionsV76.11 vs. V76.12 What constitutes “high risk”?CMS considers the following patients to behigh risk: Has a personal history of breast cancer (V10.3) Has family history of breast cancer (V16.3) Mother Sister Daughter Had her first baby after age 30 (V15.89) Has never had a baby (V15.89) Assign V76.11 as primary, above assecondary133D Rendering -76376/76377 76376 3D rendering with interpretation and reportingof computed tomography, magnetic resonanceimaging, ultrasound, or other tomographicmodality; not requiring image post-processingon an independent workstation 76377 3D rendering with interpretation and reportingof computed tomography, magnetic resonanceimaging, ultrasound, or other tomographicmodality; requiring image post-processing on anindependent workstationAHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved147

Radiology CodingNotes/Comments/Questions3D Rendering - 76376/7637776375 Deleted for 2006 2D no longer separately billable CoronalSagittalMultiplanarOblique reformatsfrom 2D axial imagesClinical Examples in Radiology, Volume 2, Issue 1: Winter 2006153D Rendering -76376/76377Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006 New codes represent complex renderings: Shaded surface Volumetric rendering Quantitative analysis (segmental volumes andsurgical planning) Maximum Intensity Projections (MIP) Performed on scanner or independentworkstationShould not be reported in conjunction withCTA, MRA, PET, CT colonography, nuclearmedicine codes or the Category III cardiac16CT/CTA codes.AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved8

Radiology CodingNotes/Comments/Questions3D Rendering -76376/76377 Required documentation Test order Do I need an order from the referringdoctor to bill for 3D rendering? Radiology Report Must the radiology report state “3Dimages acquired” or “3D imagesacquired on independentworkstation”?Clinical Examples in Radiology, Volume 2, Issue 1: Winter 2006ACR Coding Source, November/December 2005173D Rendering -76376/76377Clinical Examples in Radiology Volume 2, Issue 1; Winter 2006 What does “concurrent supervision”mean? Active participation in and monitoring ofprocess Design of anatomic region Determination of tissue types and structuresto be displayed Determination of the images or cine loops tobe archived Monitoring and adjustment of 3D workproduct18AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved9

Radiology CodingNotes/Comments/QuestionsPET 78811 - 78813 Radiopharmaceutical injectedAcquisition and reconstruction of PET datain multiple planesPhysician reviews the study for adequacyand determines if additional acquisitionsare neededImages are interpreted by physician andcompared with any prior imaging studiesQuantification of an abnormality is madeby the calculation of the SUV whenclinically indicated19PET/CT 78814-78816 Radiopharmaceutical injectedAcquisition of CT data and reconstructionof PET data in multiple planesUsing a computer workstation, the physicianoverlays PET and CT images to create imagesfor anatomic correlationPhysician reviews 3 sets of images PET Scans CT anatomical localization data Combined - images superimposedImages are interpreted by physician andcompared with any prior imaging studiesQuantification of an abnormality is made by thecalculation of the SUV when clinically indicatedAHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved2010

Radiology CodingNotes/Comments/QuestionsPET and PET/CT 78814 – 78816 reported once per imaging sessionThe PET/CT codes designate that the CT portionof the procedure is for attenuation correctionand anatomical localization.CT other than that for attenuation correction andanatomical localization (diagnostic CT) is reportedusing the appropriate site specific CT code withmodifier -59Sites are able to bill a diagnostic CT procedurewhen it is separately ordered and medicallynecessary with a PET/CT scanIf billing separately for FDG HCPCS code A955221PET and PET/CT We have a PET/CT Integrated System andthe referring physician’s initial orderstates PET study. Can we perform and billa PET/CT?A referring physician has ordered adiagnostic CT and a PET/CT for anatomiclocalization on the same day. Our currentPET/CT integrated system is capable ofperforming diagnostic CTs. How are thesestudies coded?SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved2211

Radiology CodingNotes/Comments/QuestionsPET and PET/CTWe have a PET/CT Integrated System. Areferring physician has ordered adiagnostic CT and a PET/CT for anatomiclocalization on the same day. Our currentPET/CT integrated system is capable ofperforming diagnostic CTs. How are thesestudies coded?If a PET/CT and a diagnostic CT areperformed on the same day, how are thesestudies coded? SNM Comments/Guidelines for PET/CT with Integrated Systems, July 200523PET and PET/CT Who can make the determination thata PET/CT and a diagnostic CT arerequired?We have a PET only system, but weacquire a CT for fusion following thePET scan. Can we use the PET/CT CPTcodes 78814-78816?SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005Source: ACR Coding Source, July/Aug 2005AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved2412

Radiology CodingNotes/Comments/QuestionsPET and PET/CT We are fusing PET scans with both CTand MRI studies NOT acquiredconcurrently with integrated systems,how do we code for these studiesincluding the fused images?SNM Comments/Guidelines for PET/CT with Integrated Systems, July 200525PET and PET/CT Can I report 3D rendering in additionto a PET and PET/CT for anatomiclocalization procedure if the reportdocuments this was completed?Do I code and bill separately usingCPT or HCPCS Level II codes for thePET radiopharmaceuticals?SNM Comments/Guidelines for PET/CT with Integrated Systems, July 2005AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved2613

Radiology CodingNotes/Comments/QuestionsUS DocumentationGuidelines - CPT Permanently recorded images withmeasurements, when such measurementsare clinically indicated.A final, written reportComplete vs. limited To code complete – a description of elements or thereason an element could not be visualized (eg,obscured by bowel gas, surgically absent etc.). If less than the required elements for a "complete"exam are reported (eg, limited number of organs orlimited portion of region evaluated), the "limited" codefor that anatomic region should be used once perpatient exam session.27US DocumentationGuidelines - CPT Doppler evaluation of vascular structures isseparately reportable (other than color flowused only for anatomic structure identification).93875-93990Ultrasound guidance permanently recorded images of the site to be localized documented description of the localization process,either separately or within the report of the procedurefor which the guidance is utilized. Use of ultrasound, without thorough evaluationof organ(s) or anatomic region, imagedocumentation, and final, written report, is notseparately reportable.28AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved14

Radiology CodingNotes/Comments/QuestionsUS DocumentationGuidelines - CPT For those anatomic regions that have "complete"and "limited" ultrasound codes, note the elementsthat comprise a "complete" exam. The reportshould contain a description of these elements orthe reason that an element could not be visualized(eg, obscured by bowel gas, surgically absent etc.).If less than the required elements for a "complete"exam are reported (eg, limited number of organsor limited portion of region evaluated), the "limited"code for that anatomic region should be used once perpatient exam session. A "limited" exam of ananatomic region should not be reported for thesame exam session as a "complete" exam of that29same region.US Guidelines - Abdomen LiverGall bladderCommon bile ductPancreasSpleenKidneysUpper abdominal aortaInferior vena cava30AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved15

Radiology CodingNotes/Comments/QuestionsLimited US - Abdomen If an US is performed on 2 quadrants(LLQ & RLQ) is it appropriate to bill76705 twice?AMA CPT Assistant, April 200331Retroperitoneum Complete KidneysAbdominal aortaCommon iliac artery originsInferior vena cava,If clinical history suggests urinarytract pathology include Kidneys Urinary bladder32AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved16

Radiology CodingNotes/Comments/QuestionsAbdominal andRetroperitoneal Both abdominal US andretroperitoneal US include kidneys Can both be reported?ACR Coding Source, July/August 200533Pelvic vs. Retroperitoneal What code should be reported for: Kidneys and urinary bladder? Kidneys only? Bladder only?ACR Coding Source July/August 2005CPT Guidelines34AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved17

Radiology CodingNotes/Comments/QuestionsTransabdominal US - 76856 Includes the complete evaluation of the female pelvic anatomy. description and measurements of the uterus and adnexalstructures, measurement of the endometrium, measurement of the bladder (when applicable), a description of any pelvic pathology (eg, ovarian cysts,uterine leiomyomata, free pelvic fluid). Applicable to a complete evaluation of the male pelvis. evaluation and measurement (when applicable) of theurinary bladder evaluation of the prostate and seminal vesicles to theextent that they are visualized transabdominally any pelvic pathology (eg, bladder tumor, enlarged prostate,free pelvic fluid, pelvic abscess).35Transabdominal andTransvaginal US If order states Pelvic US, and bothtransabdominal and transvaginal areperformed can both be coded? If a T/A US does not yield an adequateexamination (i.e. ovaries and adnexanot visualized due to superimposeddistended gas-filled loops of bowel) aT/V exam is medically necessary tofully evaluate the ovaries and adnexa Code the T/V study (76830) inaddition to the T/A studyAHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved3618

Radiology CodingNotes/Comments/QuestionsOB vs. Pelvic US Patient presents with an established diagnosis ofpregnancy and signs and symptoms that could bepregnancy related Report the OB US code (76801-76815) Outcome that patient is not pregnant or has an USdiagnosis that might not be related to pregnancy(eg, acute appendicitis, torsed ovary, necroticfibroid). Report the OB US code (76801-76815)AMA CPT Assistant, October 200137OB vs. Pelvic US Patient presents without an established diagnosisof pregnancy presents with gynecologicalproblems necessitating ultrasound evaluation (eg,dysmenorrhea, oligomenorrhea, menstrualirregularity, pelvic pain) Report code 76856 or 76857. Use of these codes whether or not the outcomeof the US is the diagnosis of pregnancy or acomplication related to a pregnancy.AMA CPT Assistant, October 2001AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved3819

Radiology CodingNotes/Comments/QuestionsOB and Abdominal US Decision to order and perform an abdominalUS is based on indications independent of thestate of the patient's pregnancy status, evenif the abdominal complication of a pregnancyis suspected (eg, pyelonephritis secondary toureteral obstruction by a pregnancy orsuspected cholecystitis in a pregnant patientwith right upper quadrant pain). The abdominal ultrasound codes 76700, 76705should be reported for an ultrasound of theabdomen when signs and symptoms indicate thenecessity of an abdominal ultrasound procedure.AMA CPT Assistant, October 200139OB - 76815Use 76815 for a quick look of one ormore of elements in code Code 76815 per exam, not fetus Modifier not appropriate for multiplefetusesAMA CPT Assistant, March 200340AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved20

Radiology CodingNotes/Comments/QuestionsOB - 76816Reassessment of fetal size andinterval growth Re-evaluate anatomic abnormalitieson a previous US Code once per fetus Append modifier -59 for eachadditional fetus AMA CPT Assistant, March 2003, Nov 200341Ultrasound GuidanceCPT 2005 clearly states thatpermanent images of the target areaare required when imaging guidanceis utilized. Limited sonography of the target areais included in imaging guidancecodes. ACR Coding Source, Sept/Oct 200542AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved21

Radiology CodingNotes/Comments/QuestionsUltrasound Guidance Is the radiologist required to state inthe report "permanent images arestored?” Radiologist is required to dictate astatement about the localization process,eg, ultrasound guidance was used forneedle placement, NOT that permanentimages are stored. “Permanent images" should beretrievable in the event of a practiceaudit.ACR Coding Source, January/February 200543US w/ US Guidance Patient presents with an order for anUS-guided thoracentesis orparacentesis and the technologistperforms a limited US to evaluatehow much fluid (if any) is present andin which location. Is it appropriate to charge a limiteddiagnostic US in addition to the guidanceand procedure code?ACR Coding Source, September/October 2005AHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved4422

Radiology CodingNotes/Comments/QuestionsUS Guidance –Vascular Access CPT code 76937 specifically lists the requirementsfor using this code: ultrasound evaluation of the potential accesssites documentation of selected vessel patency concurrent real-time ultrasound visualizationof vascular needle entry permanent recording and reporting.45Duplex Scans Combines Doppler and conventionalultrasound Conventional US: view structure ofblood vessels Doppler US: view movement andspeed of blood through the vessels Duplex ultrasound produces imagesthat can be color coded to showphysicians where blood flow isblockedAHIMA 2007 Audio Seminar SeriesCPT Codes Copyright 2006 by AMA. All Rights Reserved4623

Radiology CodingNotes/Comments/QuestionsUS and Duplex –To Code or Not to Code? Doppler studies should NOT be routinelyperformed and billed in conjunction with USWhen it is medically necessary to perform avascular study in conjunction withultrasound of an organ, it is appropriate toreport the vascular study separately,however, to code a duplex study, true vascular analysisneeds to be performed duplex should not be coded when color is justturned on to determine if a structure is vascular47Ultrasound and Duplex NCCI edits allow -59 modifierEdits designed to prevent inappropriateuse of the noninvasive Doppler imagingcodes when Doppler is performed with a real-time USstudy for anatomical structure identification where an evaluation of blood flow is performedfor a valid medical reason in addition to grayscale evaluation, billing

PET/CT 78814-78816 Radiopharmaceutical injected Acquisition of CT data and reconstruction of PET data in multiple planes Using a computer workstation, the physician overlays PET and CT images to create images for anatomic correlation Physician reviews 3 sets of images PET