2015 Radiology Coding Survival Guide

Transcription

1 2015 Radiology Coding Survival Guide Chapter 3: Spine and Pelvis ( ) In addition to learning the X-ray, computed tomography, and magnetic resonance codes for the spine and pelvis, you should be alert for the procedures your radiologist may perform with the radiological supervision and interpretation codes. Troubleshoot all kinds of spine and pelvis claims with the information below. Tip: For information on CTAs, see "Special Feature: Keep Sight of Anatomic Site to Select CTA Code" in Chapter 1. Watch for Separate Sessions When Choosing Spine X-Ray Codes If your radiologist performs three single cervical views, should you report (Radiologic examination, spine, single view, specify level) and add modifiers to the second and third, or should you use (Radiologic examination, spine, cervical; 2 or 3 views)? The answer may seem obvious, but the solution to this problem depends on what you mean by "three or less single views." If the three or less repeated views are all obtained as one examination, the three or less single views are the same as "three views or less." In this case, your best bet is Code represents one view of the spine any level. Code exists specifically for two or three views of the cervical spine. The standard exam includes AP (anteroposterior), lateral, and open-mouth odontoid views. Another way: If the physician repeats the three single views as serial examinations (perhaps during the stabilization of a cervical fracture or dislocation or as localizing views during cervical disc surgery), the correct strategy is to code each as a separate single-view exam and provide documentation to ensure that they are not rejected as duplicate bills. How to do it: Report 72020, (Repeat procedure or service by same physician or other qualified health care professional), (Distinct procedural service). Tackle 72020, Bundle A patient may sometimes have a cross-table C-spine (72020, Radiologic examination, spine, single view, specify level). The radiologist clears the cross table, and then later the same day the patient has a C-spine series (72050, Radiologic examination, spine, cervical; 4 or 5 views). If the documentation supports medical necessity for both exams, you may report and on the same claim. Remember: Append modifier 59 (Distinct procedural service) or other appropriate modifier to to indicate that the patient had the cross-table exam at a separate session. Caution: To submit the cross-table as a separate exam with modifier 59 or other appropriate modifier, the two exams must be performed at distinctly separate sessions. If the cross-table is taken and the C-spine series is performed immediately or shortly thereafter, then you should consider only the C-spine part of the series. Special Feature: 1 Hospital Fluoro Rule Every Radiology Practice Must Know CPT offers you plenty of fluoroscopy codes, but if your radiologist is seldom in the operating room performing the fluoro, what do you do? Here's the scoop on what the authorities have to say. Size Up the CPT Standpoint

2 The AMA, which publishes CPT codes, has offered you authoritative support for this rule. "Because fluoroscopic imaging requires personal supervision, a fluoroscopic code should not be submitted if the physician is not present in the operating room [OR] during a procedure that uses fluoroscopy or fluoroscopic guidance," as per AMA's Guidelines. This position matches the recommendations that the American College of Radiology (ACR) has been offering for years. Snag: Often the radiologist isn't present and only sees one or two films taken in the OR during the fluoro-guided procedure, and you have to decide how to code. What to do: If the radiologist/hospital contract requires the radiologist to give a formal interpretation, you may report the appropriate X-ray code based on the area the radiologist evaluates, CPT Assistant states or if the physician who provides the study asks the radiologist for a formal report from permanent images, you also may report an X-ray code based on the radiologist's documentation. Example: You code for a hospital-based radiologist and get the following report findings: Portable C-arm examination of the lumbar spine demonstrates needle positioned at the level of the L5 vertebra for epidural injection and pain management. Key: The radiologist only performed the film reading nothing else. Solution: Because the radiologist is not present and does not perform the fluoro, you should report the plain one-view film code ( , Radiologic examination, spine, single view, specify level; Professional component). Look to for 4 or 5-Views Cervical Spine X-Ray If you perform all of the anteroposterior (AP), lateral, flexion and extension views of the cervical spine, (Radiologic examination, spine, cervical; 4 or 5 views) is the code that you should use. AP, lateral, flexion, and extension views add up to four views, so (... 4 or 5 views) is a more accurate choice than (Radiologic examination, spine, cervical; 6 or more views). For 72052, your X-ray technologist must document at least six views. These views might include AP, lateral, both obliques (two views), and flexion and extension etc. But watch out: If the provider didn't document the types of views, you can't tell whether she performed a complete series. That means you can't choose If the doctor dictates only five cervical spine views (without specifying type), the highest code you can assign is Let your providers know that documenting the types of views not just the number is essential for you to choose the proper code. Lumbosacral: Stay Flexible to Handle Bending Views Scenario: Your radiologists routinely perform AP, lateral, obliques, and spot views that you code using (Radiologic examination, spine, lumbosacral; minimum of 4 views). If one radiologist also performs flexion and extension views in addition to the other views for a particular patient, should you report (... 2 or 3 views), too? Solution: No. You should not report in addition to for this situation because CPT offers a more appropriate code. If you perform AP, lateral, obliques, spot, and the flexion/extension bending views, you should report (... complete, including bending views, minimum of 6 views) for all the images explained: If the spine exam includes a minimum of four views, and those views include an AP, a lateral, and the obliques LPO (left posterior oblique) and RPO (right posterior oblique) then you code What to watch for: The obliques usually are done by laying the patient on his side and bringing the leg on top forward, which causes the torso to twist, or also by rolling the patient to a 45 degree angle. You also may see documentation of a "lateral spot," which is a small spot film of the lumbosacral junction (fifth view). Code covers all four views and the spot film explained: The descriptor for states, "complete including bending views, minimum of 6 views" and this

3 exam would include any and all images performed of the lumbar spine during an exam. Bending views include films taken of the spine with the patient standing up and bending to the sides (left and right), flexion views (when you bring the chin down toward the chest), and extension (when you lift your head toward the ceiling). Important distinction: CPT also offers (Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views), which you should use when the only images that are done are the bending views. The key element in code is a minimum of two views. Bottom line: The main thing to look for in your lumbar spine reports is if you have any of the bending/extension views. Without those views, you are looking at or depending on the number of views you have. If you have bending views or flexion/ extension views in addition to the regular views (with a minimum of six views), then look to Key Concepts: Nail Down Supervision Levels The Medicare Physician Fee Schedule supervision indicators show the physician supervision level required for a diagnostic test. The Fee Schedule lists each supervision level in number format (such as "01", "02" and so on). You can find explanations of the supervision levels in the Medicare Benefit Policy Manual, Chapter 15, Section 80. Some of the ones you'll see most often include the following: Level 0 or 09: Procedures listed in these categories are not subject to the supervision requirements. Level 01 refers to general supervision. What this means: The physician must provide direction and control during the procedure, but the physician's presence is not required. For example, most payers only require general supervision during plain X-ray films. Level 02 is direct supervision. What this means: The physician must be present in the office suite and immediately available to furnish assistance and direction, but the physician does not have to be in the room where the patient undergoes the test. Examples of procedures requiring direct supervision include joint MRIs with contrast materials (such as the technical component of 73222, Magnetic resonance [e.g., proton] imaging, any joint of upper extremity; with contrast material[s]), certain CT scans (such as the technical component of 72133, Computed tomography, lumbar spine; without contrast material, followed by contrast materials] and further sections), and several other procedures. Level 03 is personal supervision. What this means: The physician must be in attendance in the room during the procedure. For example, the technical components of (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) require personal supervision. Pelvis Code May Solve Sacrum, Coccyx Confusion When you get a report for "MRI of LS spine and sacrum and coccyx," be prepared. You should report a pelvis MRI code ( ) when you examine the sacrum and sacroiliac joints with magnetic resonance imaging. One pelvis code should cover both the sacrum and coccyx MRI. You may report one of the following lumbosacral (LS) spine MRI codes separately as long as you have orders, medical necessity, and documentation for both studies. The correct codes will depend on the documentation of contrast: Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material with contrast material(s) Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material[s] and further sequences; lumbar. Example: Your chart shows that the physician performed all studies with contrast. You should report (Magnetic resonance [e.g., proton] imaging, pelvis; with contrast material[s]) and Separate Lumbar Plexus from Lumbar Your best bet for a lumbar plexus MRI is (Unlisted magnetic resonance procedure [e.g., diagnostic, interventional]). Here's why: Lumbar MRI codes 72148, 72149, and (Magnetic resonance [e.g., proton] imaging, spinal canal and

4 contents, lumbar... ) specify "spinal canal," which is the space in the vertebrae the spinal cord passes through. The lumbar plexus is a nerve network situated in the posterior part of the psoas muscle and in front of the lumbar vertebrae transverse processes, which are bone projections muscles attach to. So the lumbar spinal canal codes aren't appropriate for a lumbar plexus MRI. The lumbar region is between the diaphragm and the pelvis, so codes (Magnetic resonance [e.g., proton] imaging, pelvis...) also would not be correct. Special Feature: Troubleshoot Coding for Urological Disorder Imaging Exams Get a leg up on common urology imaging issues with the answers to two commonly asked coding questions. 1: Overcome Abbreviation Troubles Question: You have an urologist who likes to send orders using abbreviations, such as CT Stone Protocol or CT Scan Abdomen/Pelvis I-. How can you make sure you have adequate information to code? Answer: A protocol isn't the same as an order, and protocols vary from region to region and specialty to specialty. "Protocol" has no meaning in CPT, so there's no way to code correctly if that's all the information you have. An unusual abbreviation such as "I-" is a red flag in audits and makes coding difficult. Documentation should include only standard abbreviations if it includes any at all. (Some providers use "I-" to indicate "without ionic contrast" and "I+" for "with ionic contrast.") Try this: Use a standard CT order form that lists several options. Example: You can base your form on this sample: Contrast: Without With W&WO Perform 3-D/Multi-Plane Reconstructions (If Necessary): Yes _ Renal Mass Protocol (Abdomen with and without contrast) _ Stone Protocol (Abdomen contrast) _ Other (Specify) Radiologist Discretion No Remember: Radiological procedures also require a written report signed by the interpreting physician and documentation of medical necessity. How to code: If the documentation shows abdominal and pelvic CTs without contrast, report the combination using (Computed tomography, abdomen and pelvis; without contrast material). 2: Gather Help from ACR Guidance Question: Is there any guidance on what counts as an abdominal CT and what counts as a pelvic CT? Answer: According to The American College of Radiology guideline, a typical abdominal CT ( ) includes "transaxial images from the dome of the diaphragm to the iliac crest," which is the upper border of the pelvic bone. A typical CT of the pelvis ( ) extends "from the iliac crest to the ischial tuberosities," the lower end of the pelvic bone. Separate Codes for IVP and CT IVP

5 A CT IVP (intravenous pyelogram) may mean different things at different practices and for different diagnoses, so check your documentation to determine the exact services your radiologist provided before you code. A CT IVP is most accurately an abdominal and a pelvic CT without contrast followed by with contrast: Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions Some practices perform the examination as "with contrast" only for certain diagnoses. Frequently, a CT IVP consists of an unenhanced (non-contrast) helical CT exam of the abdomen and pelvis: (Computed tomography, abdomen and pelvis; without contrast material). Note: Urography codes describe conventional, plain-film IVP, which involves intravenous contrast administration followed by X-ray (not CT) imaging. You shouldn't use these plain-film codes to described CT IVP. Case Study: Learn How to Avoid the Pitfalls of CT Coding If you get spooked by having to choose CT codes based on contrast use or deciding which diagnosis codes to claim, read step by step through this real report for tips on how to choose the proper code. Abdominal and pelvic CT with enhance, CT reformation body Dictated report: CT of abdomen and pelvis Indication: 26-year-old female with abdominal pain, rule out acute appendicitis Technique: Contiguous axial images were obtained from the lung bases through the pubic symphysis following the uneventful administration of oral and intravenous contrast, 150 cc Isovue-300 at 3 cc/sec. FOV=32 cm. Findings: Lung windows demonstrate subpleural opacity in the right lower lobe, likely representing atelectasis. No parenchymal nodule or mass within the visualized lung bases. No pleural or pericardial effusion. The liver, gallbladder, adrenal glands, spleen, pancreas, and kidneys are normal. The bladder is adequately distended without evidence for bladder wall thickening. Both ovaries are visualized, contain normal-appearing follicles. There is also a 2.1- x 1.4-cm physiologic cyst within the right ovary. The appendix is distended, contains a few 3- to 4-mm appendicoliths, demonstrates abnormal bowel wall enhancement, and is associated with moderate adjacent periappendiceal fat stranding. The remaining bowel is normal. No periappendiceal fluid collection or abscess. Impression: Acute appendicitis. Verify Contrast to Choose CPT Smart start: If you quickly skim the report, you'll see that you're coding two complete examinations a CT of the abdomen and a CT of the pelvis. The physician's documentation must include discussion of the anatomical structures of both the abdomen and pelvis for you to code CT studies of both sites. You also need to have orders for CT studies of both the abdomen and pelvis and documentation of medical necessity before you code. In our sample report, the radiologist notes the state of the abdominal structures (liver, gallbladder, pancreas, intestines) and the pelvic structures (bladder, ovaries). As a result, you can narrow your CPT choices to the CPT codes (Computed tomography, abdomen and pelvis; without contrast material), (Computed tomography, abdomen and pelvis; with contrast material[s]) and (Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material[s] and further sections in one or both body regions), rather than code series (Computed tomography, abdomen...) and (Computed tomography, pelvis...).

6 Next: To select the appropriate code, determine if the provider performed the studies with contrast, without contrast, or with a complete examination prior to and after the administration of contrast. Oral and rectal contrast studies are not considered "with contrast" studies. You'll find this rule spelled out in your CPT manual in the CT guidelines. The manual states that "contrast" refers only to contrast agents supplied intravascularly, intrathecally, or intra-articularly. Our report indicates one set of images, with the use of intravenous contrast in addition to oral contrast. Result: You'll be choosing the code that indicates CT with contrast: Computed tomography, abdomen and pelvis; with contrast material(s) Don't Settle: Require a Definitive Diagnosis Red flag: The CT is to "rule out" appendicitis, but you should never code a diagnosis because a physician wants to rule it out. Good news: The impression confirms acute appendicitis, without mention of peritonitis (540.9). But if you don't have a definitive diagnosis, you should report signs and symptoms. A chart for a patient who needs a CT to rule out appendicitis may reveal symptoms such as (Abdominal pain; right lower quadrant), (Nausea with vomiting), and 780.6x (Fever). But don't assume check the documentation to be sure. Size Up Secondary Diagnoses If your report includes findings that are incidental not causing the problem that needs medical attention you aren't required to code them, but it's OK to report them as secondary diagnoses. The ICD-9 guidelines allow you to add a diagnosis code for the ovarian cyst (620.2, Other and unspecified ovarian cyst) that is documented in the findings of our sample report, but you aren't required to report this as the primary diagnosis. You should not report atelectasis (518.0, Pulmonary collapse), though. Why: The physician records this as "likely" atelectasis, which isn't a definitive diagnosis. Coding round-up: After analyzing your report, you should post the following CPT and ICD-9 codes: (primary diagnosis) (optional). Investigate Requirements for Reporting Pelvic MRA Scenario: Your radiologist documented visualizing the following vessels through MRA: infrarenal abdominal aorta, celiac artery, superior mesenteric artery, and the renal arteries. She also visualized these vessels (both right and left): common, internal and external iliacs, common femoral, superficial femoral, profunda, popliteal, tibioperoneal, anterior and posterior tibial, and peroneal. Which codes should you report, and which vessels belong to abdominal, pelvic, and lower extremity? Answer: For this session, you should report (Magnetic resonance angiography, abdomen, with or without contrast material[s]) and (Magnetic resonance angiography, lower extremity, with or without contrast material[s]). Watch out: When the radiologist documents MRA of the abdomen and both legs, experts say you should not separately report a pelvic MRA (72198, Magnetic resonance angiography, pelvis, with or without contrast material[s]). Abdomen: If the radiologist had only documented the following MRA studies, you would report alone: Infrarenal abdominal aorta Celiac artery Superior mesenteric artery Renal arteries.

7 Lower extremity: You would report alone if you have documentation of only right and left MRAs of the following arteries: Common femoral Superficial femoral Profunda Popliteal Tibioperoneal Anterior and posterior tibial Peroneal. Because these are both right and left MRAs, you will need to indicate this on your claim. Depending on your payer, you may report two units, append modifiers LT (Left side) and RT (Right side), or modifier 50 (Bilateral procedure). Pelvic: If the radiologist documented MRA of only the common, internal, and external iliacs, you could report a pelvic MRA (72198). But remember that because the radiologist performed both abdominal and lower- extremity MRAs during the same session in your case, you should not report the pelvic MRA separately. Tip: Medicare often limits pelvic MRA coverage to urinary organ neoplasms (189.x, Malignant neoplasm of kidney and other and unspecified urinary organs) and iliac artery aneurysms (442.2, Aneurysm of iliac artery). Match Cervical Myelography and Injection Codes When deciding which procedure code to pair with myelography code 72240, there are a few tips you should keep in mind. If you are reporting both the injection procedure and the radiological supervision and interpretation (RS&I), consider these codes: Myelography, cervical, radiological supervision and interpretation Injection procedure for myelography and/or computed tomography, lumbar(other than C1-C2 and posterior fossa) Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment. Check your documentation to determine the appropriate injection codes. In most cases, the physician performs a cervical myelogram by injecting contrast into the lumbar spine and positioning the patient so that the contrast flows upward into the neck. For this procedure, you should report and In some instances, the physician will inject the contrast directly into the cervical spine (for example, by lateral cervical puncture). For this procedure, you should report and Remember that if the physician studies more than one area of the spine (for example, if the radiologist performs a cervical and thoracic myelogram or a cervical and lumbar myelogram), report (Myelography, two or more regions [e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical], radiologic supervision and interpretation) rather than Note: Fluoroscopy is an integral part of this procedure, so don't code for it separately. Steer Clear of Unless You Meet These Requirements

8 You may be tempted to report an epidurogram for epidural steroid injection guidance instead of the appropriate fluoroscopy code (77003), but that's a sure way to sink your claim. Stop denials in their tracks with the following tips on accurate coding. Think 'Diagnostic' for An epidurogram (72275, Epidurography, radiological supervision and interpretation) is a diagnostic tool, which means documentation should support medical necessity for the test and offer a description of the findings. For example: Documentation should show the physician injected contrast into the epidural space under direct fluoroscopy for a diagnostic study. The report might indicate that he studied the flow, noting any obstructions of contrast in the space around the nerves to help him diagnose compressive lesions, narrowing and swelling around the nerve or nerve roots, or intervertebral disc herniations. Keep in mind: You may report only if the physician performs the separate diagnostic study, including a permanent radiologic image of the epidural space, with interpretation and written report. CPT states that includes (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]), so you would not report them together. Dig Into Radiology Report Guidelines You need a written report signed by the interpreting physician to charge an epidurogram (72275). Remember: The American College of Radiology (ACR) has very specific guidelines for documenting diagnostic image findings. For example, they advise physicians that the report should include a description of the studies and/or procedures performed and any contrast media (including concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Key Concepts: Count Discography Levels for Reporting Discography is one service in which the number of interpretations can match the number of injections. You may submit (Discography, lumbar, radiological supervision and interpretation) for each level of the procedure. If the radiologist also performs the injection, report (Injection procedure for discography, each level; lumbar) for reporting each injection. Modifier note: If your physician treats multiple levels, append modifier 51 (Multiple procedures) to Some carriers, however, request to append modifier 76 (Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional) instead of reporting multiple units of the same radiology services on the same date. Verify your carrier's policy to ensure you append the correct modifier. Bilateral check: Code carries a bilateral status indicator of "0" in the Medicare Physician Fee Schedule, meaning that additional payments for bilateral injections do not apply. Even if your physician injects contrast from two different sides of the disc, you should not report modifier 50 (Bilateral procedure) because payers consider this only one injection procedure for diagnostic study purposes. - Published on