2015 Radiology Coding Survival Guide

Transcription

1 2015 Radiology Coding Survival Guide Section IX : Miscellaneous Services Not all services radiologists provide are listed in the Radiology chapter. Vascular and nonvascular interventions, noninvasive physiologic studies, and many other services all require venturing outside of the range. Comb Key Components to Choose Consult Substitute You finally may have gotten comfortable with the idea that radiologists may code consultations, but CMS declared that consult codes are taboo for its patients. What to do: CMS's decision means that you should report an appropriate non-consult E/M code for Medicare patients when the visit meets CPT 's consult requirements. Apply these tips to boost your chances of capturing every E/M correctly the first time. Don't Expect an Easy Crosswalk The rule: Medicare derecognized the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for telehealth consultation G codes) and increased the work RVUs for new and established office visits as well as for initial hospital and initial nursing facility visits on a budget neutral basis. Example: In the past, if a physician in the office setting performed a consult for an established patient that involved detailed history, detailed examination, and medical decision making of low complexity, you would have reported (Office consultation for a new or established patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity...). But from 2010 onwards, for Medicare patients receiving that same service, (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ) is the appropriate code, if the consulting physician or another physician of the same group practice and specialty hasn't seen the patient in the last three years. (Note that any face-t- -face service resets the three year window.) If the patient was seen within the last three years, (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ) is the correct code because consult codes are not recognized by Medicare. The key is to match the key components performed to the appropriate E/M code. Bolster Your Documentation, Dx for Inpatients Inpatient visits come with a separate challenge. In the past, only the admitting physician reported initial hospital care codes ( , Initial hospital care, per day, for the evaluation and management of a patient ). If your radiologist saw the patient separately at the admitting physician's request, such as for resting leg pain, you might have billed an inpatient consult. But with the no-pay policy on consult codes, CMS has allowed specialists to bill initial hospital care for their first inpatient visit. Modifier addition: Because multiple physicians may report the initial hospital care codes during a patient's visit, the admitting physician who oversees the patient's care must append modifier AI (Principal physician of record) to the initial visit code. Note that the modifier consists of the letter "A" and the letter "I": "AI." Other physicians performing an initial hospital E/M on the patient should not append modifier AI; those physicians should report only the appropriate level E/M code without a modifier.

2 Dx tip: Your ICD-9 codes also may help you support why two physicians are necessary on the same patient's hospital care. Separate ICD-9 codes will help substantiate the medical necessity for providing consultative services. In other words, if an auditor reviews your hospital code ( , Initial or Subsequent hospital care, per day, for the evaluation and management of a patient ) documentation, different diagnoses will show why more than one physician's E/M was necessary for the same patient. The physicians also should be very clear in their documentation. If two physicians from different specialties are treating the same problem, there needs to be a clear medically necessary reason why the additional physician is there. The doctor's documentation should include the reason he needed to see the patient. Continue to Watch for Consult Updates The CPT still reflects the consult codes, so other payers may continue to accept them. Be sure to check so you meet all necessary requirements, such as having a written request on file. Learn These Secrets to Separate Aspiration and Biopsy If you have trouble telling the difference between a core biopsy and fine needle aspiration (FNA), you aren't alone. But you are at risk of miscoding the procedures. Here's the lowdown on how you should code each. Biopsy Report = Core Biopsy Code? You know that you should use different codes for FNA and core biopsies. Unfortunately, your radiologist's notes may make determining which procedure he performed difficult. Physicians may use biopsy as a universal term to mean that they took a specimen sample. If your radiologist is in this habit, you may miscode his procedures assuming he performed a core biopsy when he performed an aspiration. A few hints will help you know what you can and can't use to tell the terms apart. Needle size: Don't count on the needle size to tell you which procedure the radiologist performed. Although a fine needle is more common for aspiration and a larger cutting needle is more common for obtaining a core tissue sample, "any size needle can be used," stresses the "ACR Coding Source" article in the March 2006 ACR Bulletin. Sample type: Aspiration typically takes a small sample of cells or fluid, while a core biopsy takes a core tissue sample rather than a few cells, the ACR Bulletin states. Because of this difference, aspirate samples go to pathology for cytologic examination. Core biopsy samples, on the other hand, undergo histologic evaluation. If you are uncertain about which procedure the radiologist performed, be sure to verify before coding. Anatomic Location Matters for Core Only Once you've identified the procedure, you need to choose the appropriate code. You report core biopsies according to anatomic site and also code for any guidance the radiologist uses. For fine needle aspiration, you typically use (Fine needle aspiration; with imaging guidance) regardless of anatomic site. And you again report any guidance used. Exception: For fine needle bone aspirations, you should use (Aspiration and injection for treatment of bone cyst). Remember to always choose the most accurate code CPT offers. Note that CPT offers another FNA code, (... without imaging guidance), but your radiologist is unlikely to perform FNA without guidance. How to find core codes: Rather than having a single code for core biopsies, you need to look for the anatomic sitespecific surgery code. For example, suppose a radiologist takes a core biopsy of the thyroid. When you look in the surgical section of the CPT manual under endocrine system and the subheading "thyroid gland," you find (Biopsy thyroid, percutaneous core needle).

3 Speed tip: To quickly locate an exact core biopsy code, look up "needle biopsy" in CPT 's index. Find the anatomical location the radiologist biopsied, such as "lung," and you'll find the code: (Biopsy, lung or mediastinum, percutaneous needle). Be sure to double check the code in the manual to be certain you have the most appropriate option. Get Your Guidance Coding in Gear Whether you're reporting FNA or core biopsy, you'll choose from the same guidance code options, depending on modality: Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation. For image-guided percutaneous needle (core) biopsy, you may see ultrasound (76942) most often, although fluoro (77002) is common too. And according to the ACR, CT (77012) can help in cases when the radiologist needs a better look at the anatomy, such as for patients with difficult to access lesions or unusual anatomy, or when he needs to plan a route to avoid vital structures. Differentiate between Core and FNA biopsies If the radiologist performs both an FNA and a core biopsy on the same lesion because the first procedure didn't yield an adequate sample, you can report the FNA procedure in addition to the core biopsy service as per CPT guideline. The FNA specimen is usually examined for adequacy when the specimen is aspirated. If the specimen is adequate for diagnosis, it is not necessary to obtain an additional biopsy specimen. However, if the specimen is not adequate and another type of biopsy (e.g., needle, open) is subsequently performed at the same patient encounter, the FNA procedure code may also be reported with the core biopsy code, while appending modifier 59 (Distinct procedural service) to the FNA code. Additionally, the FNA code needs to be sequenced after the core biopsy code. Reality: Although both the AMA/ACR Clinical Examples in Radiology (Vol. 1, Issue 3) and CPT Assistant (August 2002) state that you may report both services if both are medically necessary, coders report that proving medical necessity for both services is tough. Be sure you have strong documentation to support your choice of codes, and you follow the payer guidelines Service? Pull Out the ABN, Says CMS Stop expecting Medicare to cough up payment for thermal intradiscal procedures (e.g , Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level) or the guidance used for them. Here's why: On Dec. 8, 2008, CMS issued a national coverage determination (NCD) stating Medicare does not cover these thermal intradiscal procedures services. Contractors also must deny claims for the following codes when the narrative identifies the service provided as a thermal intradiscal procedure: Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, Lumber Unlisted procedure, spine Unlisted procedure, nervous system. And not only are the procedures non-covered, but payers must deny any fluoroscopic or radiologic guidance performed

4 with them as well, according to the NCD. What to do: "Providers are liable for charges if [a thermal intradiscal procedure] is used in surgery, unless the beneficiary was informed that he/she would be financially responsible prior to performance of the procedure. To avoid this liability the provider should have the beneficiary sign an ABN," the NCD states. TIPs tip: In radiology, you're accustomed to seeing the acronym "TIPS" refer to transjugular intrahepatic portosystemic shunt. Don't get confused CMS refers to thermal intradiscal procedures also using the term "TIPs," and those procedures are what the NCD covers. Navigate Your Iliac Intervention Choices Two years back, coders received new codes to help report services more accurately, including endovascular revascularization. Specifically, CPT added several new Category I codes to represent lower extremity endovascular revascularization, meaning angioplasty, atherectomy, and stenting. Here s how CPT divides the codes: Iliac: , Revascularization, endovascular, open or percutaneous, iliac artery Femoral, popliteal: , Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral Tibial/peroneal: , Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral In this article, iliac artery services are the focus. 1. Watch Procedure and Vessel to Choose Among The Category I iliac service codes are as follows: 37220, Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty 37221, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed , Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) , with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure). Reading through the definitions, you see that the codes for iliac services differ based on whether you re coding a service in an initial vessel or in an additional vessel. Your options also differ based on whether you re reporting (1) angioplasty alone or (2) stenting, with angioplasty if performed. On the other hand: Whether a physician performs the procedure percutaneously, via open exposure, or via a combination of the two will not affect your code choice. The codes are appropriate for any of those methods. 2. Learn How Stent and Angioplasty Affect Coding For most of the codes in the range, you should report the one code that represents the most intensive service performed in a single lower extremity vessel. All lesser services are included in that code. Warning: Iliac coding is a special case. If the physician performs iliac atherectomy in the same vessel as angioplasty or stent placement, it is appropriate to report one code for atherectomy and a second code for the angioplasty and/or stent placement. Use Category III code (0238T, Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel) to capture the atherectomy service on an iliac vessel. Apply the rule: When the radiologist performs a stent placement and angioplasty in the initial iliac vessel, you should report only That code covers both stent placement and angioplasty (when performed). You should not report (angioplasty) in addition to in this scenario. When performed : If the radiologist places a stent in an iliac artery but does not perform angioplasty, or is still appropriate because those codes specify that the angioplasty is included when performed. The codes do not indicate angioplasty is required.

5 3. Include RS&I and More in The new Category I codes bundle selective catheterization, radiological supervision and interpretation, and treatment. Specifically, guidelines explain that in addition to the intervention performed the Category I codes include: Accessing the vessel Selectively catheterizing the vessel Crossing the lesion Radiological supervision and interpretation (RS&I) for the intervention performed Any embolic protection used Closure of arteriotomy (incision in the artery) Imaging performed to document the intervention was completed. Report separately: If the physician performs mechanical thrombectomy (such as ), thrombolysis (such as 37201, 75896), or both, to help restore blood flow to the occluded area, CPT states you may report those services separately. Cat. III clue: In contrast to the Category I codes, 0238T (and the other codes in that family) include only the atherectomy and the RS&I for the atherectomy. 4. Tackle Territory Vs. Vessel Vs. Lesion The codes ( ) apply to different territories. Each territory has its own specific set of guidelines. Codes fall under the iliac vascular territory. CPT specifies that the iliac territory is divided into 3 vessels: common iliac, internal iliac, and external iliac. As already discussed, and are appropriate for the initial vessel treated. That means they apply to the first iliac artery treated in a single leg. If the physician treats one or two additional iliac vessels in the same leg, then you should choose from and Crucial: You may use up to two add-on codes per leg. The reason is that there are three iliac vessels in each leg, and you may report one code per vessel. Be sure you catch that because the codes apply per vessel you should not report add-on codes for additional lesions in a single vessel. CPT is very clear that when more than one stent is placed in the same vessel, the code should be reported only once. 5. Check Rule for 1 Intervention in 2-Artery Lesion In some cases, a lesion may extend from one artery into another. If the radiologist can treat that lesion with a single intervention, then you should choose a single code to report that service. CPT offers the example of stenosis that extends from a common iliac into the proximal external iliac. If the physician uses a single stent to treat the lesion, you should report initial vessel code You should not also report additional vessel code On the other hand, if the stenotic lesions involve two separate iliac arteries divided by a bifurcation with a break in stenosis requiring multiple therapies, then you should report an initial code as well as an additional code. 6. Look Out for Work in Both Legs The codes state that they are unilateral, which means they apply to a service on a single side of the body. CPT suggests that if the physician treats the identical territory (such as iliac) in both legs at the same session, you should use modifier 59 (Distinct procedural service) to show both legs are involved. This holds true even when the mode of therapy is different in each leg, such as angioplasty in the left leg and both angioplasty and stent in the right leg. Keep alert for payers modifier preferences, though, as some may prefer you to use modifier 50 (Bilateral procedure), modifiers RT (Right side) and LT (Left side), or some combination of modifiers for procedures on both legs Cover Your Femoral/Popliteal Coding Options

6 Proper revascularization coding requires more than just reading code definitions. You also have to take a careful look at the guidelines that apply to the individual codes to be sure you re using the codes correctly. The femoral/popliteal service codes are below. Note that all of the codes include angioplasty in the same vessel when that service is performed: Angioplasty: 37224, Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal angioplasty Atherectomy (and angioplasty): 37225, with atherectomy, includes angioplasty within the same vessel, when performed Stent (and angioplasty): 37226, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Stent and atherectomy (and angioplasty): 37227, with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed. Remember: The general rule for is that you should report the one code that represents the most intensive service performed in a single lower extremity vessel. (See Apply This Territory Rule to Avoid Denials below to learn what counts as a single vessel.) All lesser services are included in that one code. For example: When the radiologist performs a stent placement, atherectomy, and angioplasty in the left popliteal vessel, you should report only That code covers stent placement, atherectomy, and angioplasty. You should not report (angioplasty), (atherectomy), or (stent placement) separately or in addition to in this scenario. Check Out the Change From Component Coding As explained for iliac revascularization, guidelines state that, in addition to the intervention performed, the codes include: Accessing the vessel Selectively catheterizing the vessel Crossing the lesion Radiological supervision and interpretation for the intervention performed Any embolic protection used Closure of arteriotomy (incision in the artery) Imaging performed to document the intervention was completed. Don t forget: If the physician performs mechanical thrombectomy (such as , primary, or , secondary), thrombolysis (such as 37201, 75896), or both, to help restore blood flow to the occluded area, you may report those services separately. Apply This Territory Rule to Avoid Denials The codes ( ) apply to different territories. Each territory has its own specific set of guidelines. Codes fall under the femoral/popliteal vascular territory. Key rule: CPT states that the entire femoral/popliteal territory in 1 lower extremity is considered a single vessel for CPT reporting. As a result, you should report a single code even if the radiologist performed various interventions for various lesions in the popliteal artery and in the common, deep, and superficial femoral arteries in the same leg at the same session. In these situations, you should use the code for the most complex service. For example: If the radiologist performs angioplasty in the left popliteal artery and atherectomy in the left common femoral, you should report atherectomy code only. Don t forget: The codes are unilateral, which means they apply to a service on a single side of the body. CPT indicates that if the physician treats the identical territory (such as femoral/popliteal) in both legs at the same session, you should

7 use modifier 59 (Distinct procedural service) to show both legs are involved. But watch out for payers modifier preferences. Some may prefer you to use modifier 50 (Bilateral procedure), modifiers RT (Right side) and LT (Left side), or some combination of modifiers for procedures on both legs Provide a 3-Vessel Approach for Tibial/ Peroneal Claims If you ve got a handle on the iliac and femoral/popliteal revascularization codes, you re on your way to mastering the tibial/peroneal codes, as well. But this last group has rules all its own. Here s what you need to know. Initial/Additional Designation Is Key to Accuracy The tibial/peroneal service codes are below. Note that all of the codes include angioplasty in the same vessel when that service is performed. Initial vessel: The first four codes apply to the initial tibial or peroneal vessel treated in a single leg: Angioplasty: 37228, Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal angioplasty Atherectomy (and angioplasty): 37229, with atherectomy, includes angioplasty within the same vessel, when performed Stent (and angioplasty): 37230, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Stent and atherectomy (and angioplasty): 37231, with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed. Additional vessel: The final four codes are add-on codes that you use to report services on each additional ipsilateral (same side) vessel treated in the tibial/peroneal territory. Heed the use with notes following each descriptor: Angioplasty: , Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) (use with ) Atherectomy (and angioplasty): , with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37229, 37231) Stent (and angioplasty): , with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37229, 37230, 37231) Stent and atherectomy (and angioplasty): , with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37231). Remember: The general rule for the revascularization codes is that you should report the one code that represents the most intensive service performed in a single lower extremity vessel. All lesser services in that vessel are included in that one code. Consider These Services Included in the New Codes As explained for the other revascularization codes, guidelines state that, in addition to the intervention performed, the codes include: Accessing the vessel Selectively catheterizing the vessel Crossing the lesion Radiological supervision and interpretation for the intervention performed Any embolic protection used Closure of arteriotomy (incision in the artery) Imaging performed to document the intervention was completed.

8 But remember: If the physician performs mechanical thrombectomy (such as , primary, or , secondary), thrombolysis (such as 37201, 75896), or both, to help restore blood flow to the occluded area, you may report those services separately. Count Vessels Carefully -- Especially TP Trunk The revascularization codes ( ) apply to different territories, which each have distinct guidelines. Codes fall under the tibial/peroneal vascular territory. The tibial/ peroneal arteries include: Anterior tibial (AT) Posterior tibial (PT) Peroneal. As you can see, this list equates to three vessels in each leg for the tibial/peroneal territory. Because you may report one code per vessel, you may use one initial code and up to two add-on codes per leg (for a total of three vessels). The threevessel approach is similar to the iliac territory, but it differs from the femoral/popliteal territory, which counts as a single vessel for coding. Keep in mind that because the codes apply per vessel you should not report add-on codes for additional lesions treated in a single vessel. CPT is very clear that when more than one stent is placed in the same vessel, the code should be reported only once. In addition, in some cases, a lesion may extend from one artery into another. If the radiologist can treat that lesion with a single intervention, then you should choose a single code to report that service. Mark this: Work performed on the tibioperoneal (TP) trunk is bundled into the code you choose for peroneal or posterior tibial work. As the guidelines explain it, The common tibial-peroneal trunk is considered part of the tibial/peroneal territory, but is not considered a separate, fourth segment of vessel in the tibio-peroneal family for CPT reporting of endovascular lower extremity interventions. The guidelines go on to indicate that if the physician treats lesions in the TP trunk as well as in the PT artery, you should choose a single code. Master Coding for 2 Legs or 2 Territories The revascularization codes are unilateral, which means they apply to a service on a single side of the body. CPT indicates that if the physician treats the identical territory (such as tibial/peroneal) in both legs at the same session, you should use modifier 59 (Distinct procedural service) to show both legs are involved. But watch out for payers modifier preferences. Some may prefer you to use modifier 50 (Bilateral procedure), modifiers RT (Right side) and LT (Left side), or some combination of modifiers for procedures on both legs. On the other hand: If the radiologist treats more than one territory in the same leg, then you should report multiple codes, according to CPT. For example, if the radiologist places a stent in the peroneal and performs angioplasty in the internal iliac, you should report both for the peroneal service and (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty) for the iliac service. These are both initial codes because each service is the initial service in a distinct territory. Apply the Tibial/Peroneal Lessons to This Example Consider this sample case in which a patient has a three-vessel tibial artery occlusion proven by angiography. The physician uses antegrade femoral access and selectively catheterizes the AT, PT, and peroneal arteries. He performs atherectomy in the TP trunk and the AT, PT, and peroneal arteries. He then performs percutaneous transluminal angioplasty (PTA) in the same vessels. Solution: The codes you should report are: AT atherectomy: PT atherectomy: Peroneal atherectomy: Note the use of modifier 59 on the second atherectomy code to make it clear that it is a distinct service in a separate

9 vessel. Remember that you will not report every service performed using a separate code. You should bundle the TP trunk atherectomy into the peroneal or PT intervention. You also should not code selective catheterization or angioplasty separately. Here's How the G-Tube Codes Including Guidance Affect You When your physician performs percutaneous jejunostomy and gastro-jejunostomy, report these services with the following codes: Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. Beware: All the above procedures include contrast injections and fluoroscopic guidance, so you don't have to report these services separately. Three Codes for Tube Replacement Report a tube replacement with the following three codes. These codes are location specific, i.e., each of them report a separate tube replacement Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report. Imaging included in replacements, too: As with insertion codes , replacement codes include fluoroscopic guidance. To reflect this, the AMA revised (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) to remove reference to the gastrointestinal system. Coding 43760? Think Twice Note: When your physician changes a G-tube without any image guidance, you have the code (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance). But this is normally an unlikely scenario for radiology coders. Note that you cannot report (Placement, enterostomy or cecostomy, tube open [eg, for feeding or decompression] [separate procedure]). So CPT instructs you to use another set of codes (Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) and (Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report) that include fluoroscopic guidance and contrast injection(s) for insertion of a percutaneous colonic tube. Single GJ Code Still on Your Wish List While you don't have a single code for placement of a gastro-jejunostomy (GJ) tube, CPT 2008 did add (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report). A note with the code tells you that "for conversion to a gastro-jejunostomy tube at the time of initial gastrostomy tube placement, use in conjunction with "

10 Previously, CPT Assistant (October 1996) stated that you should use (Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition) "only when repositioning the gastric feeding tube after (not at the same session as) placement of the feeding tube. Any repositioning to reach the final site for enteric nutrition is included in the initial placement procedure and is not coded separately." So when the physician advanced the tube into the jejunum during initial insertion, you could report only the G-tube insertion (43750, Percutaneous placement of gastrostomy tube). However, CPT deleted code long before. But based on the new guidance, you have been able to report both (Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report) and Expect Bundles for RS&I Inclusive Codes When CPT publishes a code that includes radiological supervision and interpretation (RS&I), the RS&I codes should generally not be reported separately as per CPT guideline. The RS&I code (Change of percutaneous tube or drainage catheter with contrast monitoring [e.g., genitourinary system, abscess], radiological supervision and interpretation) is inclusive in the GI tube codes , as per these codes definition. The descriptors for all include "under fluoroscopic guidance including contrast injection(s), image documentation and report," or very similar wording. However, RS&I codes may be reported separately under special circumstances, with appropriate modifier. Always remember to check with your provider s complete documentation, your payer s preference and the latest CCI update before reporting RS&I codes separately with the respective GI tube codes. CPT Responded to Need for More Specific Ureteral Stent Code Many interventional radiologists perform ureteral stent removal and replacement. Long before, CPT 2008 provided a specific code for transurethral removal of an internally dwelling ureteral stent without cystoscopy.. Some providers were reported unlisted procedure code (Unlisted procedure, urinary system) before implementation of CPT code (transurethral removal of an internally dwelling ureteral stent without cystoscopy). Others were reported the endoscopic stent removal code (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) with modifier 52 (Reduced services). The other option has been to report only an E/M service Long before, CPT 2008 added these two codes for transurethral removal of ureteral stent via snare/ capture without cystoscopy: Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation. Watch out: You shouldn't use the codes when the physician removes a stent by an attached thread or string. When the physician uses a clamp or other instrument passed through the urethra to grasp the stent (which protrudes into the bladder) for removal or exchange, you'll use or RS&I: The removal/replacement codes include radiological supervision and interpretation (RS&I). So you should not report a separate code for radiological guidance with these services. And because physicians always perform these procedures under moderate sedation, you should not report moderate sedation separately in the facility setting. The inclusion of RS&I and moderate sedation keeps and in line with percutaneous internally dwelling ureteral stent removal and replacement codes (Removal [via snare/capture] and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation) and (Removal [via snare/capture] of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation), which CPT added in Diagnostic Disc Aspiration is no FNA When reporting percutaneous diagnostic disc aspiration, use (Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes). For imaging, you have the option of choosing 77003

11 (Fluoroscopic guidance ) or (Computed tomography guidance...) depending upon what guidance method was exactly employed. It is important to remember that disc aspiration should not be confused with the fine needle aspiration code (Fine needle aspiration; with imaging guidance) Another important point to note here is that includes injection of contrast during the imaging guidance and localization. Capture Extra Pay for Fluoro With Epidural Steroid Injection? You need to get up to speed fast if your radiologist starts offering services such as epidural steroid injections (ESIs) to help patients with pain, and we've got your CPT, ICD-9, and HCPCS bases covered. Use this comprehensive look at coding pain management ESI encounters to be sure you're getting every dime you deserve. Watch the Approach for The radiologist likely will choose an interlaminar epidural approach, placing the medicine inside the epidural space. As long as the needle is positioned in the epidural or subarachnoid space with the needle inserted "straight" in between the lamina, then the following are the correct codes: Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic lumbar or sacral (caudal). Pay attention: Be careful not to confuse single injection codes with the following codes, which you should use for continuous infusion or intermittent bolus:62318 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic lumbar or sacral (caudal). Look to for Alternative Approach If the radiologist inserts the needle at an angle into the intervertebral foramen to perform an injection at the nerve root area, this is a transforaminal (through the foramen) epidural injection. With this type of epidural, the radiologist injects the medication into the lateral epidural space, "bathing" a specific spinal nerve as it exits the spinal cord. For this approach, you'd use a different set of codes, as follows: Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level cervical or thoracic, each additional level (list separately in addition to code for primary procedure) lumbar or sacral, single level lumbar or sacral, each additional level (List separately in addition to code for primary procedure). Add-on rules: You should report and as the primary codes for the first transforaminal injection to the cervical/thoracic or lumbar/sacral levels, respectively. Use add-on codes and for each additional injection at the cervical/thoracic or lumbar/sacral levels, respectively. Example: The radiologist administers transforaminal ESIs at the right L4-L5 and L5-S1 intervertebral spaces, two different levels. You should report for the first lumbar injection and for the additional level injection.

12 Get a Handle on Coding Fluoro Increasingly, physicians are using imaging guidance to verify precise needle placement for the ESI. And, in fact, some payers won't cover ESI without this guidance. When fluoro isn t specifically included in the code, you may report fluoroscopic guidance for an ESI separately with (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]). Watch for: The physician needs to include documentation that he used fluoroscopic guidance for the procedure. Remember: If another physician performs the injection, the radiologist can't bill fluoro imaging unless he performed it personally. And you're unlikely to see one physician perform the injection and another bill the fluoro. Don't get confused: The parenthetical note following states that codes such as include "injection of contrast during fluoroscopic guidance and localization." This means that a provider cannot separately bill for the injection of contrast if performed during fluoroscopic guidance, but the note does not restrict you from reporting the guidance (77003) with these epidural injection codes. (In contrast, specifically include fluoro and CT guidance.) Payer Policy May Offer ICD-9 Answers Many payers, including most Medicare carriers and some commercial payers, have coverage policies that spell out the diagnoses that indicate ESI medical necessity. Example: Aetna states that providers should administer therapeutic selective transforaminal epidural injections as part of a comprehensive pain management program. Administration of more than three such injections per six months is subject to medical necessity review. They are generally medically necessary when used for identifying the etiology of pain in persons with symptoms suggestive of chronic radiculopathy, where the diagnosis remains uncertain after standard evaluation (neurologic examination, radiological and neurodiagnostic studies). The following are some of the conditions and corresponding ICD-9 codes that many payer policies say, support ESI medical necessity: Displacement of intervertebral disc without myelopathy Degeneration of intervertebral disc x Postlaminectomy syndrome , 724.0x Spinal stenosis , Neuritis or radiculitis... Remember: You must base your ICD-9 code on the documentation. You should never choose a code based solely on what the payer covers. Call on HCPCS for In-Office Injection In addition to the procedure and diagnosis, you may report the steroid used if your practice bears the cost, such as when you perform it in the physician's office. Drugs the physician may use include the following: Kenalog (J3301, Injection, triamcinolone acetonide, not otherwise specified, 10 mg) Celestone Soluspan (J0702, Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg) Depo-Medrol (J1020-J1040, Injection, methylprednisolone acetate...) Aristopan (J3303, Injection, triamcinolone hexacetonide, per 5 mg). The physician may also use Versed (J2250, Injection, midazolam HCl, per 1 mg) for moderate sedation. Try This ESI Example Now that you've read about ESI CPT, ICD-9 and HCPCS coding, decide how you would code the following ESI scenario, and then check your answer below.

13 Example: In the office, your physician administers an L3-L4 interlaminar lumbar ESI for a patient with a herniated lumbar disc. He uses fluoroscopy to guide needle placement, and the drug injected is Depo-Medrol, 40 mg. Solution: You should report the single lumbar interlaminar injection with (Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)) and the fluoroscopy with (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)). Report the Depo- Medrol with J1030 (Injection, methylprednisolone acetate, 40 mg). For the diagnosis, you should report (Displacement of lumbar intervertebral disc without myelopathy). Coding Tips to report Your practice may use ankle/brachial indices (ABIs) to help diagnose some of the 8 million Americans who have peripheral arterial disease. But if you miss CPT 's guidance on hard copies for noninvasive arterial studies, you could be headed for trouble. Work your way through these important rules to keep your accuracy rate at its best. 1: Single Vs. Multiple Matters Take a close look at the descriptors for these noninvasive arterial study codes: Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels) Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more level(s), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia). The key distinction is that you should use for a limited exam performed at one or two levels of each leg, for example, and for an exam of 3 or more levels of each leg. 'Segmental' tip: For 93923, you may run across the term "segmental." For example, radiologists may perform the test either on a single level or at segmental (various) limb levels. You may even hear the equipment used to perform the studies referred to as "segmental machines." 2: Arms, Legs, or Both Required? If the radiologist performs complete bilateral studies of the arms and legs at 3 or more levels, coders often wonder whether one or two units are appropriate. Solution: You should report two units of AMA's CPT Assistant (June 2001) explains that the use of the word "or" in the descriptor (... studies of upper or lower extremity arteries ) means that you should report once for the arms and once for the legs. The same rule applies to 93922: 1 or 2 levels bilateral studies of the arms and legs merit two units of (guidelines instruct reporting 93922, ). 3: Use 52 in Specified Cases You may sometimes see the radiologist perform a study on only one side. Both and 93923's descriptors specify

14 "bilateral." You need to review the guidelines to know when you should append modifier 52 (Reduced services) to or The guidelines instruct you to report limited code (without modifier 52) when the physician performs a unilateral exam for three or more levels, or uses provocative functional maneuvers, on a patient with only one arm or leg available for study (as in the case of an amputee). Experts recommend the following list to help you count levels: Lower Extremity Levels 1. High thigh 2. Low thigh 3. Calf 4. Ankle 5. Metatarsal 6. Toes Upper Extremity Levels 1. Arm 2. Forearm 3. Wrist 4. Digits 4: Heed This ABI Hard Copy Warning The ABI is the most common of these physiologic studies and measures blood pressure at the ankle and elbow using a Doppler stethoscope. Careful: Code 93922's descriptor refers to "ankle/brachial indices." But if your radiologist uses a handheld device that doesn't produce a hard copy, you should not report CPT guidelines for "Noninvasive Vascular Diagnostic Studies" state that the "use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system, and is not reported separately." Here's why: Providers use these handheld Dopplers in physician offices to listen to the carotid arteries and infant hearts in utero. The provider uses them just to listen they are not designed to provide diagnostic information. What to do: Before you use or 93923, be sure you meet these CPT guideline requirements: "Vascular studies include patient care required to perform the studies, supervision of the studies and interpretation of study results with copies for patient records of hard copy output with analysis of all data, including bidirectional vascular flow or imaging when provided." 5: Dig Into LCD for Additional Requirements Protect yourself: Check your own LCD (local coverage determination) on these studies. Payers may not consider an ABI alone sufficient for reporting or They may require additional elements listed in the codes descriptor. You should include an ABI in office visit services when you perform it without other vascular studies. You may need