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					2007 PMCC

Chapter 19
                 Chapter Outline
•    Introduce students to
    1.   Radiology concepts to include the types of radiology
         •   CT
         •   MRI
         •   PET
         •   Materials and Equipment common to the radiology
    2.   Terminology in the CPT® specific section in relation to
         the procedure
    3.   Relevant rules and regulations that impact radiology
         services and procedures
• Learning how to select and correctly apply radiology codes
   – Involves multiple levels of understanding
• An accomplished coder must have a general recognition of
   – Various types of radiology equipment
   – Determine which equipment is required for each diagnostic evaluation,
   – Be generally familiar with anatomical positions and views commonly
• Whether or not contrast material has been administered will also
   – Affect code assignment
• The application of coding conventions and modifiers unique to
  diagnostic radiology as well as
   – The determination of how a physician’s order or final radiology
     report can be translated in CPT, HCPCS, or ICD-9-CM for coding
       • Poses further challenges
           Medical Necessity
• Medical necessity is best illustrated by a
   – Solid, accurate, and specific diagnosis
• Diagnoses must reflect a
   – Sign, symptom, condition, or injury
• In the case of a screening film
   – A ―V‖ code diagnosis must be used to indicate
     what problem is under surveillance or screening
• Documentation for medical necessity of radiology
  services generally requires
   – A statement of the diagnostic impression of the referring
     physician with
   – An indication of the patient’s relevant signs and
• The setting and need for these services must be
  documented to be
   – Safe and effective, appropriate for the diagnosis, not for
     convenience, and based on a need not met by a service
     previously performed
• Diagnostic Coding
  – The Official ICD-9-CM Guidelines for Coding
    and Reporting provides
     • Guidance on coding and is a part of ICD-9-CM
       Coding Guidelines for Outpatient Services
        – Which provides guidance on diagnoses coding
          specifically for outpatient facilities and physician
          offices, and
        – Has instructed physicians to report diagnoses
          based on test results
 Primary ICD-9-CM Codes for
      Diagnostic Tests
• Ordered Due to Signs and/or Symptoms
  – If the physician has confirmed a diagnosis based
    on the results of the diagnostic test
     • The physician interpreting the test should code that
  – If the diagnostic test did not provide a diagnosis,
    or was normal
     • Interpreting physician should code the sign(s) or
       symptom(s) that prompted the treating physician to
       order the study
 Primary ICD-9-CM Codes for
      Diagnostic Tests
• Reason for the Testing
   – An order may include the following forms of communication
       • A written document signed by the treating physician/practitioner, which
         is hand-delivered, mailed, or faxed to the testing facility
       • A telephone call by the treating physician/practitioner or his/her office
         to the testing facility; and
       • An electronic mail by the treating physician/practitioner or his/her
         office to the testing facility
   – On the rare occasion when the interpreting physician does not have
     diagnostic information as to the reason for the test and the referring
     physician is unavailable to provide such information
       • It is appropriate to obtain the information directly from the patient or
         the patient's medical record if it is available
       • However, an attempt should be made to confirm any information
         obtained from the patient by contacting the referring physician
 Primary ICD-9-CM Codes for
      Diagnostic Tests
• Incidental Findings
   – Should never be listed as primary diagnoses
   – If reported, incidental findings may be reported as
       • Secondary diagnoses by the physician interpreting the diagnostic test
• Unrelated/Co-Existing Conditions/Diagnoses
   – Unrelated and co-existing conditions/diagnoses may be reported as
       • Additional diagnoses by the physician interpreting the diagnostic test
• Diagnostic Tests Ordered Without Signs and/or Symptoms
   – When a diagnostic test is ordered in the absence of signs/symptoms
     or other evidence of illness or injury
       • The physician interpreting the diagnostic test should report the reason for
         the test as the primary ICD-9-CM diagnosis code
       • The results of the test, if reported, may be recorded as additional diagnoses
 Primary ICD-9-CM Codes for
      Diagnostic Tests
• ICD-9-CM Coding to Highest Level of Specificity
   – The interpreting physician should code the ICD-9-
     CM code that provides
      • The highest degree of accuracy and completeness for
        the diagnosis resulting from test, or for the sign(s)/
        symptom(s) that prompted the ordering of the test
   – In the context of ICD-9-CM coding, the "highest
     degree of specificity" refers to
      • Assigning the most precise ICD-9-CM code that most
        fully explains the narrative description of the
        symptom or diagnosis
 Procedure Coding Guidelines
• Bilateral Procedures
   – When bilateral procedures are performed, and not specified in the
     procedure narrative as ―unilateral‖ and/or ―bilateral,‖
       • Report the procedure using the correct CPT code plus modifier
   – Document the medical necessity through
       • Appropriate use of ICD-9-CM diagnosis codes
   – Bilateral views performed only for comparison purposes typically
     are coded as a single procedure
• Combination Procedures
   – When the medical necessity of combination procedures can be
      • Code separately when separate imaging is performed for each
   Procedure Coding Guidelines
• Noninvasive/Interventional Diagnostic Imaging
   – Noninvasive/interventional diagnostic imaging includes
      • Standard radiographs, single /multiple views, contrast
        studies, CT, and MRI
   – The CPT manual allows for various combinations of codes
      • To address the number and type of radiographic views
   – In the event that radiographs have to be repeated in the course
     of a radiographic encounter due to substandard quality
      • Only one unit of service for the code can be reported
 Procedure Coding Guidelines
• Noninvasive/Interventional Diagnostic Imaging
   – If additional films are necessary due to a change in the patient’s
       • The films can be reported separately
   – The CPT descriptor for many of the services refers to a minimum
     number of views
       • If more than the minimum number specified is necessary, and no
         other more specific code is available
            – Only that service should be reported
• Orders
   – According to the CMS
      • An order is a communication from the treatment physician or
        practitioner requesting that a diagnostic test be performed on a
      • The order may conditionally request an additional diagnostic test if
            – The result of the initial diagnostic test ordered yields to a certain value
              determined by the treating physician
 Procedure Coding Guidelines
• Referrals
   – The American College of Radiology (ACR) states
      • ―Radiologists, either directly/indirectly, should work with their
        referring physicians to eliminate any ambiguity over the
        procedure ordered. In doing so, the referral justifies the coding.
        With increasing frequency, third party payers are looking for
        inconsistencies between the study ordered versus the one billed.‖
      • Medicare now covers diagnostic testing that includes diagnostic
        x-ray, when ordered by the physician treating the patient
• Unlisted Codes
   – When using unlisted procedure codes, providers should
     send the payer, including Medicare
      • A description of the nature, extent, and need for the procedure,
        including the time, effort, and equipment necessary
• CPT or HCPCS modifiers may be required to
   – Alter a code’s description
   – Pinpoint an anatomic location or
   – Better define the circumstances under which the service
     was rendered
• In CPT, two digit modifiers are appended to a code
• In HCPCS Level II code set
   – Modifiers can be two
      • Alpha characters or
      • Alphanumeric
        Radiology Procedures
• The practice of radiology involves many types of
  specialty tests that are
   – Code specific to body part
• The following list describe the tests
   – Often encountered when coding radiology for imaging
• Computerized Tomography (CT)
   – Produce a series of transverse or axial images
   – These transverse images are routinely translated into
     coronal and/or sagittal views
         Radiology Procedures
• Digital Subtraction Angiography (DSA)
   – Diagnostic imaging technique that applies computer technology to
     fluoroscopy for
       • The purpose of visualizing the same vascular structures observable with
         conventional angiography
   – Since the radiographic contrast material can be injected into a vein
     rather than an artery
       • The procedure reduces the risk to patients
       • Can be done on an outpatient basis
• Displacement Cardiography
   – Cardioymography—noninvasive diagnostic test used in evaluating
     coronary artery disease
   – The diagnostic exam may be used as an adjunct to
     electrocardiographic stress testing in evaluating
       • Coronary artery disease for male patients, with atypical angina pectoris
         or nonischemic chest pain
       • Female patients, angina, either typical or atypical
      Radiology Procedures
• Gastrophotography
  – The photographic record of gastrointestinal disorders aids
    in the
     • Documentation and evaluation (healing or worsening) of lesions
       such as the gastric ulcer
     • Facilitates consultation between physicians concerning difficult-
       to-interpret lesions
     • Provides preoperative characterization for the surgeon
     • Permits better diagnosis of postoperative gastric bleeding to
       determine necessity of reoperation
• Magnetic Resonance Imaging (MRI)
  – MRI is a noninvasive method of graphically representing
     • Distribution of water and other hydrogen rich molecules in the
       human body
       Radiology Procedures
• Magnetic Resonance Imaging (MRI) continued
  – In contrast to conventional radiographs or CT scans, in
    which the image is produced by x-ray beam attenuation
    by an object
     • MRI is capable of producing images by several techniques
  – Various combinations of MR image production methods
    may be employed to
     • Emphasize particular characteristics of the tissue or body part
       being examined
  – MRI is useful in examining the
     • Head, central nervous system, and spine
  – MRI can assist in differential diagnosis of
     • Mediastinal and retroperitoneal masses, including abnormalities
       of the large vessels such as aneurysms and dissection
        Radiology Procedures
• Multiplanar Diagnostic Imaging (MPDI)
   – Process that translates the data produced by CT scanning by
       • Providing reconstructed oblique images that can contribute to diagnostic
   – Also known as
       • Planar image reconstruction or
       • Reformatted imaging
• Positron Emission Tomography (PET)
   – Noninvasive diagnostic imaging procedure that assesses the level of
     metabolic activity and perfusion in various organ systems of the body
   – A positron camera (tomograph) is used to produce cross-sectional
     tomographic images
       • Obtained from positron emitting radioactive tracer substances
         (radiopharmaceuticals) such as 2-[F-18] Fluoro-D-Glucose (FDG), that
         are administered intravenously to the patient
        Radiology Procedures
• Single-Photon Emission Computed Tomography (SPECT)
   – SPECT acquires information on the
      • Concentration of radionuclides introduced into the patient’s
   – Useful in the diagnosis of several clinical conditions including
       • Stress fracture, spondylosis, infection (eg, discitis), tumor (eg,
         osteoid osteoma) analysis of blood flow to an organ, as in the case
         of myocardial viability
• Ultrasound Diagnostic Procedures
   – Involve
       • Low energy sound waves are being widely employed to
         determine the composition and contours of nearly all body
         tissues except bone and air-filled spaces
   – Technique permits
       • Noninvasive visualization of even the deepest structures in the
      Equipment and Supplies
• Contrast Media
   – Can be
      • Administered through multiple routes
      • Made of more than one substance
   – Administration of contrast may come through the
      • Artery, vein, joint, subarachnoid, or subdural (intrathecal) space of
        the spinal cord, mouth, or rectum
   – Contrast material administered orally or rectally is considered to
       • Without contrast
• Films: Scout, Comparison, Diagnostic, Screening and Spot
   – Scout films may be performed prior to an actual imaging study with
     contrast or delayed imaging
   – Scout films are not coded separately
        • Considered part of the basic procedure
   – In some instances, a screening film is used to detect an undiagnosed
     illness or condition
        Equipment and Supplies
• Films: Scout, Comparison, Diagnostic, Screening and Spot
   – Screening films may be used to
      • Prediagnose or confirm a suspected condition
   – To further define the presence of an injury or pathology
      • Comparison films are sometimes ordered
   – Comparison films may be ordered to
      • Pinpoint an abnormality or deformity between a normal and injured
         body part
   – Diagnostic films may be required to evaluate
       • The extent of the presenting symptoms or condition or to track the
         progression of the patient’s condition or illness
   – Spot films are submitted for a radiologist’s interpretation when
       • Another physician performs the radiology supervision and interpretation
   – Radiology supervision and interpretation codes require the radiologist to
       • Supervise the performance of the procedure and
       • Provide a written interpretation of the procedure
     Equipment and Supplies
• Portable, Hand Held X-ray Device
   – A low intensity X-ray imaging device that
     • Is a lightweight portable hand held instrument using a
        low level isotope as its penetrating energy source
     • Can picture any part of the human anatomy that can
        be inserted in the space between the energy source
        and the viewing mechanism
   – The device can be useful in making an immediate
     diagnosis in the following settings
      • Isolated areas, accident scenes, sports events, and
        emergency rooms
Views and Anatomical Planes
• Views
  – In radiology, the number of views and the number of
     • May not be the same
  – The radiologist or radiology technician may be required
     • Shoot several films in order to obtain a particular view
       ordered by the referring physician
  – However, the CPT language specifies numbers of
    views, not numbers of films taken
  – It is important for the coder to understand the concept of
     • ―Minimum number of views‖ in this CPT series
  – Coding conventions dictate that when this language is found
     • The code includes any views in excess of the minimum stated
Views and Anatomical Planes
• Anatomical Planes
   – The student should carefully study
      • Anatomical directions and positions
   – A clear understanding of these terms
      • Expedites code search and application
   – Examples
      •   Posterior —at or near the back surface of the body
      •   Superior—above, at the top
      •   Lateral—to the side
      •   Transverse—horizontal plane that divides the body
          into top and bottom sections
     Interventional Radiology
• CPT guidelines use component coding to identify
   – Injection
   – Catheter movement
   – Interpretation
• Component coding requires at least two CPT codes
   – One to identify the surgical or procedural aspect and
   – One to identify the radiological/imaging guidance and
     interpretation portion
      Vascular Catheterization
• Nonselective Catheter Placement—Catheter or needle is
  placed directly into an artery (and not moved or manipulated
  further) or is negotiated only into the aorta (thoracic and/or
  abdominal) from any approach
• Arterial Catheterization
   – Nonselective codes example
      • 36160—introduction of needle/catheter, aortic, translumbar
• Selective Catheterization—catheter must be moved,
  manipulated or guided into a part of the arterial system other
  than the aorta or vessel punctured, generally under fluoroscopic
   – Within each vascular family, only highest order catheterization is coded
   – Coding includes puncture site and final position of catheter
     Vascular Catheterization
• Catheterization
   – Venous catheterization is
      • Nonselective or selective
• Nonselective placement
   – Direct puncture of peripheral veins or the
   – Placement of the catheter in the IVC and SVC by any
• Selective catheterization includes
   – Catheter placement in those veins that arise from the
     vena cava or the vein punctured directly and
   – Any subsequent branches of the primary venous branches
  Head and Neck (70010-70559)
• Speech Study for Speech Pathology
   – CPT code 70371 describes
       • Complex dynamic pharyngeal and speech evaluation typically
         performed in conjunction with services provided by a speech
• New code for 2007
   – 70554 Magnetic resonance imaging, brain, functional MRI;
     including test selection and administration of repetitive body
     part movement and/or visual stimulation, not requiring
     physician or psychologist administration
       • Code 70554 describes a similar service, in which both the testing
         methodology and the imaging are encompassed in a single code.
         In this situation, a technologist or physicist performs the
         neurofunctional testing during the imaging
 Head and Neck (70010-70559)
• Surgical MRI
  – CPT codes 70557, 70558, and 70559 report the use
    of magnetic resonance imaging (MRI) during surgery
• Chest (71010-71555)
  – The chest x-ray is the
     • Most commonly performed x-ray and consists of PA,
       or frontal view, and a lateral, or side view
  – Measurements are used to check for various heart
• Bronchography – Unilateral & Bilateral
   – Bronchography procedures (71040, 71060) must be coded with codes
       • Describe the imaging components (radiological supervision and
         interpretation) of the procedure along with an additional code or codes
         that describe the contrast material injected or instillation, etc. (31656,
         31708, 31710, 31715)
• Spine & Pelvis (72010-72295)
   – Single View Spines – Code 72020
       • Appropriate for describing cross-table lateral of the cervical spine,
         including those performed with the portable unit in the emergency
         room. Use this code in addition with any other subsequent work
• Sacrum and Coccyx
   – CPT code 72220 includes both anatomic parts (sacrum and coccyx)
• Myelography
   – Myelography (72240, 72255, 72265, 72270) procedures
     must be assigned codes that
      • Describe the imaging component along with an additional code
        that describes the injection procedure performed
• Epidurography
   – Epidurography (72275) is used to
      • Image space occupying lesions of the spine
   – Code 72275 includes the
      • Fluoroscopic guidance and localization of the needle
      • A report is required, also, when reporting the code
• Upper Extremities and Lower Extremities
   – Arthrography – Arthrography procedures must be
     assigned codes that
      • Describe the imaging component along with an additional code
        that describes the injection procedure performed
• Abdomen (74000-74190)
   – Kidney, Ureter, and Bladder (KUB)
      • KUBs and flat plates differ only in the
          – Position of the film relative to the anatomy
      • CPT code is the same (74000)
• Gastrointestinal Tract (74210-74363)
   – Routine Upper GI procedures have a specific set of codes
      1. CPT 74240 describe upper GI performed without or with
         delayed films and without a KUB
      2. CPT 74241 describes upper GI performed without or with
         delayed firms including a KUB (do not bill additionally for the
      3. CPT 74245 describes upper GI including small bowel follow-
         through including multiple serial films
• Gastrointestinal Tract (74210-74363)
   – When routine Upper GI procedures are enhanced with
     air contrast, high-density barium, an effervescent agent
     and whether performed without or with glucagon, the
     following codes should be used instead of those above
      •        - CPT codes 74246, 74247, 74249
• Small Bowel & Colon
   – Code 74240 describes
      • Routine barium enema procedures
      • When performed with air contrast and specific high-density
        barium, report 74280
   – Code 74250 specifically describes
      • Small bowel procedures, including multiple serial films, when
        performed alone (not as a part of an upper GI)
• ERCP Codes
   – Endoscopic retrograde cholangiopancreatography
     (ERCP) CPT codes 74328, 74329, and 74330 distinguish
     among the imaging components of
      • Biliary, pancreatic, and combineed biliary and pancreatic
   – Surgical codes are required to report the actual
     catheterization (see 43260-43272)
• Urinary Tract (74400-74485)
   – Code 74400—IVPs performed intravenously, without or
     with KUB, and without or with tomography
   – Code 74415—IVPs performed by infusion, drip
     technique, and/or bolus technique, including
• Tomography continued
  – Codes that describe common interventional
    procedures include
     • Antegrade pyelogram
        – 50390 – Aspiration and/or injection of renal cyst or pelvis
          by needle, percutaneous
        – 74425 – Urography, antegrade (S&I)
  – Each portion of the interventional procedure
     • Coded separately
     • Do not consider the portion inherent in the other
• Gynecological and Obstetrical (74710-74775)
  – Hysterosalpingography (74740) and transcervical
    catheterization of the fallopian tube (74742)
     • Both interventional procedures that must be assigned
       codes that describe the
        – Imaging component along with
        – An additional code that describe the catheter insertion
          and/or injection procedure (58340, 58345)
• Vascular Procedures (75600-75996)
  – Diagnostic venography performed at the time of an
    interventional procedure is reported separately if:
     • No prior catheter-based venographic study is available and a full
       diagnostic study is performed and decision to intervene is based
       on the diagnostic study
     • A prior study is available but as documented in the medical
     • The patient’s condition with respect to the clinical indication has
       changed since the prior study
     • There is inadequate visualization of the anatomy and/or
     • There is a clinical change during the procedure that requires new
       evaluation outside the target area of intervention
• Aorta and Arteries (75600-75790)
   – Physician may call an arch exam a thoracic aortogram (75605) when
       • Evaluation of the arch and the origins of the great vessels was actually
         performed and documented
   – Cervicocerebral arch angiography (75650 involves
       • Placement of a catheter into the ascending aorta with imaging of the
         origin of the ―great vessels‖ of the aorta at this level
   – Cervicocerbral arch angiography often performed in conjunction
       •   75680 (cervical carotid bilateral)
       •   75671 (cerebral carotid bilateral)
       •   75685 (vertebral), 75716 (bilateral extremity) and
       •   75662 (external carotid bilateral)
   – If more selective catheterization is performed
       • The 36200 nonselective code is considered bundled with the selective
• Veins and Lymphatic (75801-75893)
   – Diagnostic venography performed at the time of an
     interventional procedure is reported separately if:
      • No prior catheter-based venographic study is available and a full
        diagnostic study is performed and decision to intervene is based
        on the diagnostic study, or
      • A prior study is available but as documented in the medical
      • The patient’s condition with respect to the clinical indication has
        changed since the prior study, or
      • There is inadequate visualization of the anatomy and/or
        pathology, or
      • There is a clinical change during the procedure that requires new
        evaluation outside the target area of intervention
• Transcatheter Procedures (75894-75989)
   – Coding for carotid stenting varies across the country
      • Some Medicare carriers instruct providers to report these
        services using the traditional stent placement procedure and
        supervision and interpretation codes (37205, 75960)
      • Others require that the unlisted vascular surgery procedure code
        (37799) be used
      • Still others prefer the use of applicable Category III codes
• Other Procedures (76000-76499)
   – CPT code 76000 indicates ―fluoroscopy up to one hour‖
      • Should be reported one time only per patient encounter
      • Report code 76001 is used for fluoroscopy exams over one hour
  Diagnostic Ultrasound (76506-
• Head & Neck (76506-76536)
  – Ophthalmic Ultrasound (76510-76512)
      • The ophthalmic ultrasound codes separate
          – B-scan probe (76512) from
          – Diagnostic quantitative A-scan (76511)
      • Code 76510 reports
          – Performance of both a B-scan and quantitative A-scan performed
            during the same encounter

• Corneal Pachymetry
   – CPT code 96514 corneal pachymetry
      • Ultrasonic measurement of corneal thickness
      • Used in the diagnosis and management of glaucoma
      • Reports a bilateral procedure
  Diagnostic Ultrasound (76506-
• Ophthalmic Biometry
   – Ophthalmic biometry measurements (76516, 76519, and 92136)
       • Performed bilaterally when a patient is assessed for initial cataract
       • Measurements remain accurate for months or years after their
   – CPT codes 76519 and 92136 include
       • Bilateral technical component (both eyes) and a unilateral professional
         component (one eye)
• Abdomen and Retroperitoneoum (76700-76778)
   – Code 76700 – complete abdominal ultrasound
   – Code 76770 – an exam of the retroperitoneal structures some of
     which overlap with the abdominal code
   – Code 76775 – an exam of one retroperitoneal organ or area or a
     follow-up exam of a limited area
  Diagnostic Ultrasound (76506-
• Pelvis (76801-76857)
   – Obstetrical (76801-76828)
      • Code 76815 – represents a focused ―quick look‖ exam limited to
        the assessment of one or more of the elements listed in the code
      • Code 76820—reports a procedure to assess blood flow of
        umbilical artery
   – Non-obstetrical (76830-76857)
      • Code 76830—transvaginal echography
          – Employed often in evaluating uterine, ovarian, and adnexal
            symptoms through the use of an intervaginal transducer
      • Code 76856—complete echographic study of nonpregnant
          – Performed with external transducer
  Diagnostic Ultrasound (76506-
• Extremities (76880-76886)
   – Infants with abnormal physical findings in their hip
       • May undergo sonography in the detection of acetabular dysplasia
   – Most hip problems can be treated with a brace
       • Infant wears day and night for about 3-6 months
• Ultrasonic Guidance Procedures (76930-76965)
   – Separate, written interpretation of all diagnostic
     ultrasound examinations
       • Should be produced and maintained in patient record
   – In office setting
       • Physician who owns the equipment and performs the service
           – May bill the global fee
• Other Procedures (76000-76499)
  – Several CPT codes have been deleted from this
    subsection and renumbered under new headings
     • Radiologic Guidance—further divided into new
        –   Fluoroscopic Guidance (77001-77003)
        –   Computed Tomography Guidance (77011-77014)
        –   Magnetic Resonance Guidance (77021-77022)
        –   Other Radiologic Guidance (77031)
     • Breast, Mammography (77051-77059)
     • Bone/Joint Studies (77071-77084)
• Add-on code 77001 and codes 77002 and 77003 were
  established to
   – Replace codes 75998, 76003, and 76005
   – The corresponding parenthetical notes have also been relocated with
     the newly established codes to allow for more appropriate placement
     in the new subsection for Fluoroscopic Guidance
• New codes
   – 77001 Fluoroscopic guidance for central venous access device
     placement, replacement (catheter only or complete), or removal
     (includes fluoroscopic guidance for vascular access and catheter
     manipulation, any necessary contrast injections through access site or
     catheter with related venography radiologic supervision and
     interpretation, and radiographic documentation of final catheter
     position) (List separately in addition to code for primary procedure)
• New codes
  – 77002 Fluoroscopic guidance for needle placement (eg,
    biopsy, aspiration, injection, localization device)
  – 77003 Fluoroscopic guidance and localization of needle
    or catheter tip for spine or paraspinous diagnostic or
    therapeutic injection procedures (epidural, transforaminal
    epidural, subarachnoid, paravertebral facet joint,
    paravertebral facet joint nerve, or sacroiliac joint),
    including neurolytic agent destruction
• Codes 77011-77014 were established to
  – Replace codes 76355, 76360, 76362, and 76370 to
    allow for more appropriate placement in the new
    subsection for Computed Tomographic
  – Corresponding instructional parenthetical notes
    have also been relocated with the newly
    established codes
• New codes
  – 77011 Computed tomography guidance for stereotactic
  – 77012 Computed tomography guidance for needle
    placement (eg, biopsy, aspiration, injection, localization
    device), radiological supervision and interpretation
  – 77013 Computerized tomography guidance for, and
    monitoring of, parenchymal tissue ablation
  – 77014 Computed tomography guidance for placement of
    radiation therapy fields
• New codes
  – 77021 Magnetic resonance guidance for needle
    placement (eg, for biopsy, needle aspiration, injection, or
    placement of localization device) radiological supervision
    and interpretation
  – 77022 Magnetic resonance guidance for, and monitoring
    of, parenchymal tissue ablation
     • Codes 77021 and 77022 were established to replace codes 76393
       and 76394 to
         – Allow for more appropriate placement in the new subsection for
           Magnetic Resonance Guidance
     • Corresponding parenthetical notes have also been relocated with
       the newly established codes
• New codes
  – 77031 Stereotactic localization guidance for breast biopsy
    or needle placement (eg, for wire localization or for
    injection), each lesion, radiological supervision and
  – 77032 Mammographic guidance for needle placement,
    breast (eg, for wire localization or for injection), each
    lesion, radiological supervision and interpretation
     • Codes 77031 and 77032 were established to replace codes 76095
       and 76096 to
         – Allow for more appropriate placement in the new subsection for
           Other Radiologic Guidance
     • Corresponding parenthetical notes have also been relocated with
       the newly established codes
• Add-on codes 77051 and 77052 and codes
  77053-77059 were established to
  – Replace codes 76082, 76083, 76086, 76088,
    76090, 76091, 76092, 76093, and 76094
     • Allows for more appropriate placement in the new
       subsection for Breast, Mammography
  – Corresponding parenthetical notes have also
    been relocated with the newly established codes
• New codes
  – 77051 Computer-aided detection (computer algorithm
    analysis of digital image data for lesion detection) with
    further physician review for interpretation, with or
    without digitization of film radiographic images;
    diagnostic mammography (List separately in addition to
    code for primary procedure)
  – 77052              screening mammography (List separately
    in addition to code for primary procedure)
• New codes
  – 77053 Mammary ductogram or galactogram, single duct,
    radiological supervision and interpretation
  – 77054 Mammary ductogram or galactogram, multiple
    ducts, radiological supervision and interpretation
  – 77055 Mammography; unilateral
  – 77056             bilateral
  – 77057 Screening mammography, bilateral (2-view film
    study of each breast)
• New codes
  – 77058 Magnetic resonance imaging, breast,
    without and/or with contrast material(s);
  – 77059 bilateral
• Codes 77071-77084 were established to
  – Replace 76006, 76020, 76040, 76061, 76062,
    76065, 76066, 76070, 76071, 76075-76077,
    76078, and 76400
     • Allows for more appropriate placement in the new
       subsection for Bone/Joint Studies
     • Instructional parenthetical notes have also been
       relocated with the newly established codes
• New codes
  – 77071 Manual application of stress performed by
    physician for joint radiography, including
    contralateral joint if indicated
  – 77072 Bone age studies
  – 77073 Bone length studies
    (orthoroentgenogram, scanogram)
• New codes
  – 77074 Radiologic examination, osseous survey;
    limited (eg, for metastases)
  – 77075           complete (axial and appendicular
  – 77076 Radiologic examination, osseous survey,
• New codes
  – 77077 Joint survey, single view, 2 or more joints
  – 77078 Computed tomography, bone mineral
    density study, 1 or more sites; axial skeleton (eg,
    hips, pelvis, spine)
  – 77079           appendicular skeleton (peripheral)
    (eg, radius, wrist, heel)
• New codes
  – 77080 Dual-energy X-ray absorptiometry (DXA), bone
    density study, 1 or more sites; axial skeleton (eg, hips,
    pelvis, spine)
  – 77081             appendicular skeleton (peripheral) (eg,
    radius, wrist, heel)
  – 77082             vertebral fracture assessment
  – 77083 Radiographic absorptiometry (eg,
    photodensitometry, radiogrammetry), 1 or more sites
  – 77084 Magnetic resonance (eg, proton) imaging, bone
    marrow blood supply
     Radiation Oncology (77261-
• A clinical and scientific specialty that manages
       • The treatment of patients with cancer through the use of ionizing
         radiation alone, or in combination with surgery and/or chemotherapy
   – Radiation oncology is a multidisciplinary medical specialty
       • Physicians, physicists and dosimetrist, nurses, biomedical scientists,
         computer scientists, radiotherapy technologists, nutritionists, and
         social workers
   – The physician determines a multistep treatment program for the
     patient receiving radiation oncology
   – The plan varies by patient
   – The codes selected report whether the work performed was at a
       • Simple, intermediate or complex level
   – Level established in the treatment plan
       • Must be the same for the therapy and treatment device
        Radiation Oncology
• Clinical Treatment Planning (77261-
  – The clinical treatment includes
     • Interpretation of special testing, tumor localization,
       treatment volume determination, treatment
       time/dosage determination, choice of treatment
       modality, determination of number, and size of
       treatment ports, selection of appropriate treatment
       devices, and other procedures
     • Treatment plans are designed at a simple,
       intermediate, or a complex level
     • Services are reported using codes 77261-77263
          Radiation Oncology
• Treatment Devices (77300-77370)
  – Treatment devices include
     • Beam modifying and shaping blocks
     • Patient immobilization devices
     • Beam modifiers such as wedges or compensators
  – There are three levels of complexity of treatment
     • Depends upon the difficulty of integrating the device into
       the overall treatment plan
  – See codes 77332-77334
           Radiation Oncology
• Radiation Oncology subsection has been updated to include
  a new section
   – Stereotactic Radiation Treatment Delivery
       • Includes four new codes: 77371, 77372, 77373, and 77435
   – Codes 77371 and 77372 were established to
       • Report stereotactic radiosurgery (SRS) delivery for the treatment of
         cerebral lesion(s)
       • Instructional note has been included to direct users to report code 77432
         for radiation treatment management
   – Codes 77371 and 77372 established to
       • Report the technical component of the single-fraction cranial SRS
         complete course of treatment in one session for the two SRS technical
         modalities utilized
   – Codes 77373 and 77435 were established to
       • Describe stereotactic body radiation therapy (SBRT), treatment delivery,
         and treatment management services
       • Category III codes 0082T and 0083T previously described these services
         and have been deleted
            Radiation Oncology
• Radiation Oncology continued
   – Code 77373 is intended to
       • Report SBRT treatment delivery per fraction (not to exceed 5 fractions)
       • Parenthetical note has been added following code 77373 to instruct
         users to report codes 77371 and 77372 for single fraction cranial lesions
       • An exclusionary note has been added to instruct readers not to report
         code 77373 in conjunction with codes 77401-77416 and code 77418
   – Code 77435 was established to
       • Report SBRT treatment management per treatment course (not to
         exceed 5 fractions)
       • Exclusionary note has been added to instruct readers not to report code
         77435 in conjunction with codes 77427- 77432
       • An instructional note has been added following code 77435 regarding
         the appropriate code to report when the procedure is performed jointly
         by a surgeon and a radiation oncologist (61793)
         Radiation Oncology
• Radiation Treatment Management (77427-
  – This phase of treatment is reported in
     • Units of five fractions or treatment sessions
  – The services need not be furnished on consecutive days
  – Multiple fractions representing two or more treatment
    sessions furnished on the same day
     • May be counted separately as long as there has been a distinct
       break in therapy sessions
  – Code 77427—five fractions
     • Also reported if there are three or four fractions beyond a
       multiple of five at the end of a course of treatment
  – One or two fractions beyond a multiple of five at the end
    of a course of treatment, are not reported separately
              Nuclear Medicine
• In nuclear medicine
   – Radioactive substances are placed into the body either orally or
     intravenously or by ventilated aerosol or gas
   – A camera produces an image to detect the radioactive substance as it
   – The procedures are performed in a variety of modalities represented by
     a modality-specific CPT code
• Single photon emission computed tomography (SPECT)
  studies represent
   – An enhanced methodology over standard planar nuclear imaging
• When a limited anatomic area is studied
   – There is no additional information procured by obtaining both planar
     and SPECT studies
• While both represent medically acceptable imaging studies
   – When a SPECT study of a limited area is performed, a planar study is
     not to be reported separately
               Nuclear Medicine
• Absorptiometry
• Single photon absorptiometry (code 78350)
   – Describes a noninvasive radiological technique that measures
      absorption of a monochromatic photon beam by bone material
   – Exam provides a quantitative measurement of the bone mineral of
      cortical and trabecular bone to
   – Assess treatment response at appropriate intervals
• Pulmonary Perfusion Imaging
• Code 78588--reports the imaging a patient twice
   – One after inhalation of a radioactive aerosol to determine pulmonary
     ventilation; and
   – Again after injection of a radioactive particulate to determine lung
• Procedure is used to diagnose
   – Pulmonary embolism, bronchopulmonary sequestration, and
     pulmonary trauma
             Nuclear Medicine
• Other Procedures (78800-78999)
   – Nuclear medicine codes 78800, 78802, and 78804
      • Report the studies required to complete nuclear medicine whole
        body or SPECT tumor imaging studies
   – Imaging for specific tumors detected
      • Through the infusion of labeled indium-111 antibody (78800)
        requires multiple day studies
      • Whole body imaging for pretreatment planning prior to therapy
        must be performed on two or more days
• Therapeutic (79005-79999)
   – Radio labeled monoclonal antibodies (code 79403)
      • Can locate tumor cells and either kill them or deliver tumor-killing
        substances to them without harming normal cells
   – Code 79005
      • Reports radiopharmaceutical therapy by oral administration
• Emergency Room
   – X-ray of a patient treated in the ER
      • Interpreted by both the treating physician and by radiologist
• Levels of Supervision
   – Personal Supervision—physician’s actual attendance in
     the room during the performance of the procedure
   – Direct supervision—physician must be in the medical
     office suite, and must be able to intervene immediately
   – General supervision—procedure performed under
     physician’s overall supervision and control; physician
     does not have to be present during procedure
• Mammography
  – The performance of a screening mammogram
     • Does not require signs, symptoms, or history of breast disease in
       order for the exam to be covered
  – There is no requirement that the screening
    mammography be
     • Prescribed by a physician for an eligible beneficiary to be covered
     • Payment may be made for a screening mammography furnished
       to a woman at her direct request
  – Screening mammograms denied as being performed more
    frequently than allowed under Medicare law, or because
    they were not performed at a Medicare-approved
    screening center
     • Fall under limitation and liability regulations
• Mammography continued
  – As define in the Code of Federal Regulation (CFR),
    diagnostic mammograms are radiologic procedures
    furnished to a man or woman with
     • Signs or symptoms of breast disease
     • A personal history of breast disease
     • A personal history of biopsy-proven benign breast disease
  – Documentation must include a physician’s interpretation
    of the results
  – They must be ordered by a physician or qualified
    nonphysician practitioner and
     • Are covered as often as is medically necessary
  – A specific diagnosis is required
     • ―Rule out‖ diagnosis is insufficient medical necessity
• Portable X-ray Transportation Services
  – CMS bases these services on cost of providing
    the service that, at a minimum, should include
     •   Cost out the vehicle
     •   Vehicle modifications
     •   Gasoline
     •   Staff time involved in only the transportation for a
         portable x-ray service
The End

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