CPC Chapter 17

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Chapter 17 Radiology Introduction Radiology is a branch of medicine using radiation—including ionizing radiation, radionuclides, nuclear magnetic resonance, and ultrasound—to diagnose and treat disease. Using radiography (X-rays), physicians visualize and identify internal structures. X-ray technology includes a variety of advanced applications, such as computerized axial tomography (CAT or CT scan), magnetic resonance imaging (MRI), ultrasound technology, nuclear medicine, radiation oncology, and positron emission tomography (PET). Objectives Uinderstand anatomical planes, anatomical directions, and positioning in radiology * Review key terms associated with radiology e Understand the use and coding of contrast material o Differentiate between the different types of imaging and films e Gain the knowledge of when to include additional CPT* codes from other sections e Understand the importance of parenthetic instructions » Distinguish between modifiers 26 and TC and when to use them Anatomy and Medical Terminology To obtain effective images, the radiologist or radiology technician needs to place the patient in the correct position and then adjust the equipment to the correct angle, height, and settings. Planes are the ways in which the body can be divided. The most common are the frontal (coronal) plane, cutting the body into front (anterior) and back (posterior) halves; the sagittal plane, cutting the body into right and left portions; and the transverse (axial) (horizontal) plane, cutting the body into upper (superior) and lower (inferior) halves. The midsagittal plane divides the body into equal portions of right and left. €k — CT scan Report: No visualized displaced rib fractures. There are multilevel degenerative changes of the spine. No evidence of acute fracture of the lower thoracic or lumbar spine on axial, sagittal, or coronal images. Fat-filled left inguinal canal is noted. In this CT scan report, the physician uses different plane images to verify the absence of a fracture of the lower thoracic or lumbar spine. To know what is being viewed, you need to understand directional and positional terms. Directional terms are reviewed in the Anatomy chapter. Some main positional terms include: Anatomic Position—FErect, facing forward, arms rotated outward with the palms forward, hands open with thumbs pointed out. The feet are together or slightly apart. Supine Position—Lying down on the back with the face up. This position is also known as dorsal recumbent (lying down). Prone Position—Lying face down on the front of the body. This position is also known as ventral recumbent. Lateral Position—Position in which the side of the subject is next to the film. This can be performed as erect lateral (standing side) or lateral decubitus (lying down side). Oblique Position—Slanted position where the patient is lying at an angle neither prone nor supine. In radiology, you may see Right anterior oblique (RAQO), Left anterior oblique (LAO), Right posterior oblique (RP0), or Left posterior oblique (LPO). The anterior or posterior terminology indicates the part of the body closer to the film. For example, in RAO, a person is on his right side with the anterior part of the body closer to the film. Radiological projections refer to the path in which the X-ray beam flows through the body. Radiological projections often are stated in the medical documentation and referred to in CPT® code descriptions. Common projections include: Anteroposterior (AP)—The X-ray beam enters the front of the body (anterior) and exits the back of the body (posterior). Posteroanterior (PA)—The X-ray beam enters the back of the body (posterior) and exits the front of the body (anterior). Lateral—The X-ray beam enters one side of the body and exits the other side. Lateral projections are named by the side of the body placed next to the film. Oblique—The X-ray beam enters at an angle that is neither frontal (AP or PA) nor lateral. Section Review 171 1. The axial plane divides the body into what sections? A. Left and right B. Posterior and anterior C. Frontand back D Superior and inferior Hide Answer » Answer: D). Superior and inferior Rationale: The axial plane, also known as the transverse plane, slices the body horizontally and cuts the body into inferior and superior sections.

Chapter 17: Radiology 2. What position is the body placed in when it is in an oblique position? Lying on the back, face up = Lying down, face down C. Atan angle, neither frontal nor lateral D. Lyingon the side Hide Answer » Answer: C. At an angle, neither frontal nor lateral Rationale: An oblique position is a slanted position where the patient is lying at an angle which is neither prone nor supine. 3. What X-ray projection enters the front of the body and exits through the back of the body with the patient lying down on the back? AP PA &= C. Lateral D. Oblique Hide Answer Answer: A. AP Rationale: AP is the abbreviation for anteroposterior where the projection enters the front of the body and exits through the back of the body. Because the patient is lying on their back, it cannot be oblique. 4. Which plane divides the body into anterior and posterior sections? A. Sagiual B. Axial C. Transverse D Coronal Answer: D. Coronal Rationale: The coronal plane is also known as the frontal plane and divides the body into front (anterior) and back (posterior) sections. 5. The path of the X-ray beam is known as? A. Position B. Projection C. Plane D. Sight of vision Answer: B. Projection Rationale: The projection is the path the X-ray beam takes through the body. ICD-10-CM Coding Radiology services are ordered for a wide variety of symptoms, illnesses, or screenings. Diagnostic coding supports medical necessity for radiological services. Each procedure ordered and performed must be validated by 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 Z code for the diagnosis is used to indicate what problem is under surveillance or screening. A radiology service can be performed as a routine screening or for a sign or symptom. A routine screening might be performed with a preventive medicine exam, such as a routine chest X-ray. If a chest X-ray is performed as part of a preventive medicine exam, it is coded with a Z code. Look in the ICD-10-CM Alphabetic Index for Examination/radiological. There is a subentry for with abnormal findings. These entries default to the codes for a general adult medical examination. 700.00 Encounter for general adult medical examination without abnormal findings 700.01 Encounter for general adult medical examination with abnormal findings Screening examinations are used when there are no signs or symptoms, but the provider is looking for a specific disease or illness. Such services might include mammography or a bone density study. When the radiological service is part of a screening for a particular disease or illness, such as mammography to screen for breast cancer, use the screening diagnosis from the Z codes. A routine mammography for screening of breast cancer is Z12.31 Encounter for screening mammogram for malignant neoplasm of breast.

Chapter 17: Radiology Another type of screening performed is when a patient requires clearance for surgery. When an X-ray is performed as part of a pre-operative examination, a code from Z01.810- 701.818 is used. If the sign or symptom is the only diagnosis documented, report the sign or symptom as the diagnosis for the radiological service. Similarly, when a test is ordered for a sign or symptom, and the outcome of the test is a normal result with no confirmed diagnosis, report the sign or symptom that prompted the physician to order the test. ' A physician orders a mammography for breast pain. The findings on the mammogram are normal. In this instance assign N64.4 Mastodynia as the reason for the mammography. If the radiologist interprets the radiology test, and the final report is available at the time of coding, report the confirmed diagnosis based on the report. This is specified in the ICD- 10-CM guidelines in section 1V, subsection K, Patients receiving diagnostic services only. For patients receving diagnostic services only dunng an encounter/visit, sequence first the diagnosts, condition, problem, or other reason for encounter/wisit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (for example, chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign 201.89 Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it Is appropriate to assign both the Z code and the code describing the reason for the nonroutine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. Sometimes, providers will order a radiological examination with a rule out or questionable diagnosis. In this instance, if the report has not been read and a final diagnosis given, query the physician to obtain the sign or symptom for the ordered test. A patient presents to the radiology facility with forearm pain following a schoolyard fall. The ordering physician writes the order for a two-view film of the forearm (73090). The diagnosis is rule out fractured forearm. Because rule out conditions are not assigned diagnosis codes, the following options are available for coding. If the X-ray is positive for a fracture, add the code for a closed forearm fracture. (Note: Unless the fracture is labeled open, choose the closed fracture category in ICD-10-CM.) If the X-ray is negative for a fracture, query the medical professional for the signs or symptoms (ICD-10-CM R0O0-R99) the patient exhibited. Never assume the patient was experiencing arm pain to coincide with the anatomic location of the X-ray. If no information was provided at the time of the X-ray, other than the rule out, and the X-ray is negative, there is no medical necessity for this study. Each payer may have varying guidelines on how the communication needs to be documented. INDICATION: Rule out cervical mass vs. left vocal cord paralysis CT NECKWITH CONTRAST TECHNIQUE: Axial CT cuts were obtained from the top of the orbits down to the thoracic inlet using 100 cc of Isovue 300. Axial CT cuts of 1.3 mm were also obtained through the larynx. Sagittal and coronal computer reconstniction images were also obtained. Indications for nonionic contrast: None FINDINGS: No mass lesion within the posterior nasopharynx or oropharynx. There are multifocal punctuate calcifications in the right palatine tonsil. The submandibular and parotid glands are unremarkable. There are subcentimeter anterior cervical and left submandibular lymph nodes. There are subcentimeter left internal jugular lymph nodes. The left pyriform sinus is slightly larger than the right and there is dilatation of the left laryngeal ventricle. There is probably atrophy of the left true vocal cord best seen on the 1.3 mm thick images. The left arytenoid cartilage appears to be in a deviated medial position as opposed 1o the right. The thyroid glands are unremarkable. The visualized upper mediastinum is unremarkable. Refer to the CT of the chest report. IMPRESSION 1. Left vocal cord paralysis 2. No cervical mass or adenopathy In this case, the initial reason for the CT scan is a rule out diagnosis of a cervical mass. The scan showed no cervical mass but confirmed diagnosis of left vocal cord paralysis. The Medicare Benefit Policy Manual, chapter 15, §80.6.1 outlines the guidelines for documenting orders from the treating practitioner. According to these guidelines, an order may include the following forms of communication: o 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 or her office, to the testing facility; or * An electronic mail (email) by the treating physician/practitioner, or his or her office, to the testing facility. Occasionally, the radiologist will find something she was not looking for on the X-ray. This is considered an incidental finding and is reported with an additional diagnosis. An incidental finding should not be used as a primary diagnosis. Written Interpretation Once the written interpretation is dictated and transcribed, there can be no alterations to the report for billing or coding purposes. Instances such as these occur frequently and should be brought to the attention of the radiologist for more accurate documentation on future interpretations and informative orders from the referring physician.

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Chapter 17: Radiology 1. Section Review 17.2 Mary visited her family physician for a lump in the upper outer quadrant of her left breast. The physician ordered a mammogram to rule out breast cancer. The radiologist did not find any abnormal findings. What diagnosis is reported for the professional portion of the mammography? A. (50412 B. N63.21 C. D242 D. Z12.31 Answer: B.N63.21 Rationale: When a test is ordered for a sign or symptom, and the outcome of the test is a normal result with no confirmed diagnosis, the coder reports the sign or symptom that prompted the physician to order the test. Because the test was ordered for a lump in the breast, but the outcome is normal, the lump in the breast, N63 is reported as the diagnosis. In the ICD-10-CM Alphabetic Index, look for Lump/breast/left/upper outer quadrant which directs you to N63.21. Verify code selection in the Tabular List. 2. A young boy presents to the emergency department with pain in his lower left leg after being kicked in a soccer game. The X-ray report reveals a fractured tibia and fibula. What diagnosis code(s) should the radiologist report for reading the X-ray? Do not report the external cause code(s). A. M79.609 B. S72.8X2A C. S82311A D. S82.202A, S82.402A Hide Answer » Answer: D). S82.202A, S82.402A Rationale: The final diagnosis is available at the time of reporting and is used instead of the sign or symptom. The final diagnosis of a fracture of the tibia and fibula is reported. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/tibia (shaft) $82.20-. Verify code selection in the Tabular List. In the Tabular List, a 6™ character 2, is reported for the left side and the 7" character A, is reported for the initial encounter. Final code choice: S82.202A. Next, look in the ICD-10-CM Alphabetic Index for Fracture, traumatic/fibula (shaft) (styloid) S82.40-. Verify code selection in the Tabular List. In the Tabular List, 6 character 2, is reported for the left side and the 7™ character A is reported for the initial encounter. Final code choice is S82.402A. A patient with sinusitis and left vocal cord paralysis is sent for a CT scan of the brain. The impression is vague, low-density white matter changes in the right frontal region. This is a nonspecific finding. The radiologist requests an MRI scan for further characterization. What diagnosis code(s) should the radiologist report for the reading of the CT? A. ]32.9,]38.00 B. R93.0,]32.9,]38.01 C. Re3.0 D. ]38.00 Answer: B. R93.0, ]32.9, ]38.01 Rationale: The findings of the CT were nonspecific and are not considered a final diagnosis. The first diagnosis reports the nonspecific findings. Because the findings were inconclusive, you also report the signs and symptoms for which the CT was ordered. In the ICD-10-CM Alphabetic Index, look for Findings, abnormal, inconclusive, without diagnosis/radiologic (X-ray)/head R93.0. Next, look in the Alphabetic Index for Sinusitis ]32.9. The last code is found in the Alphabetic Index under Paralysis/vocal cords/unilateral ]38.01. Verify all code selections in the Tabular List. Mr. Davis has his yearly preventive medicine exam. The physician orders a chest X-ray as a part of the preventive exam. What diagnosis is reported for the chest X-ray? A. Z01.811 B. Z00.01 C. 700.00 D. 7029 Answer: C. 700.00 Rationale: For encounters for routine radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign 700.00. Because there were no signs or symptoms for the chest X-ray, and it was routinely performed as part of a preventive medicine exam, ICD-10-CM Z00.00 is reported. In the ICD-10-CM Alphabetic Index, look for Examination/annual (adult) or Examination/radiological (as part of a general medical examination) Z00.00. In the Tabular List, the note under subcategory code 700.0 indicates the code is for an, “Encounter for adult periodic examination (annual) (physical) and any associated laboratory and radiologic examinations.”

Chapter 17: Radiology 5. A 63-year-old female is having a hip arthroplasty due to severe rheumatoid arthritis in the hip. During her pre-operative exam, a chest X-ray is taken. What diagnosis is reported for the chest X-ray? A. Mo6.9 B. 701810 C. 701811 D. 701818 Hide Answer a Answer: D. 701.818 Rationale: The pre-operative exam is a general preoperative exam. When an X-ray is performed as part of a general preoperative exam, ICD-10-CM code Z01.818 is reported. In the ICD-10-CM Alphabetic Index, look for Examination/pre-operative - see Examination, pre-procedural. Examination/pre-procedural/specified NEC Z01.818. Verify code selection in the Tabular List. cpr® Radiological procedures may be performed on any part of the body. They sometimes are performed as stand-alone services (such as a chest X-ray or ankle X-ray) or in addition to other services (such as MRI guidance for needle placement during a biopsy). To code radiological services correctly, a general recognition of the types of radiology equipment used is needed, as well as determining which equipment is used for the evaluation, and understanding the applicable guidelines in the Radiology section. Radiology Guidelines Separate Procedures As in prior chapters, designated separate procedures may be performed as an integral part to another procedure or alone. Separate procedures should be coded only if performed alone or with an unrelated service. There are very few separate procedure codes in the Radiology section. Unlisted Procedures Radiological services not covered by a specific CPT® code are reported with an unlisted code. Although most unlisted procedures end in the digits 99, in the radiology section, there are some unlisted procedures ending in 96, 97, and 98 (for example, 76496 Unlisted fluoroscopic procedure (eg, diagnostic, interventional)). Anytime an unlisted service code is reported, the claim should be accompanied by a special report describing the procedure and the reason the procedure was medically necessary. An explanation of the equipment, time, and effort involved should also be submitted. Supervision and Interpretation S&l codes describe the supervision and interpretation of a radiological procedure. Interventional radiologic procedures are used to diagnosis and treat conditions using invasive procedures. Common procedures containing a supervision and interpretation component include vascular procedures performed on the veins and arteries. When a procedure requires radiological guidance, a code from the surgery or medicine section is reported along with the supervision and interpretation code from the radiology section. When the same physician provides both the surgical procedure and the radiological guidance, the physician reports both codes. When a physician performs the surgery and a radiologist performs the supervision and interpretation, each reports the code for his or her portion of the service. For all codes, especially S&I codes, it is imperative to read the parenthetical instructions to help prevent coding errors. Note: The radiologist billing the supervision and interpretation must be present at the time of the procedure to bill the supervision and interpretation code and provide a written report. Radiology S&! codes can be reported with modifier 26 for the Professional Component or modifier TC for the Technical Component. Both modifiers are explained later in this chapter. 75959 - Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision, and interpretation. Administration of Contrast Material(s) Contrast material is a substance or material that lights up the structure being studied so it can be visualized. The phrase “with contrast” represents contrast material administered in three ways: 1. Intravascularly—using a vein or artery 2. Intra-articularly—in a joint 3. Intrathecally—within a sheath or within the subarachnoid or cerebral spinal fluid According to CPT® guidelines, “Oral and rectal contrast administration alone does not qualify as a study “with contrast” Oral contrast is either barium or a mixture of fruit juice and an iodine-containing liquid. Alternatively, the patient may receive a barium enema. When contrast is given orally or rectally, it is not appropriate to report a “with contrast™ code. Some studies, such as a magnetic resonance imaging (MRI) or computerized tomography (CT) scan, may be performed without contrast, followed by with contrast. In these instances, there often is a single code to report both sets of images. Gadolinium is a contrast used with MRIs. lodine (or a hypoallergenic synthetic) is used for intravenous pyelograms (IVP), CT scans, arthrograms, and angiograms. The radiology technician routinely asks the patient if he or she is allergic to or has shown sensitivity to shellfish (also high in iodine concentration). If the patient replies positively, a nonionic contrast substitute is infused to lessen or prevent a potential allergic reaction. When coding for contrast imaging, an additional procedure may need to be reported. Watch for parenthetic instructions following the imaging codes to see if another procedure— such as the injection procedure for the contrast—should be reported. The contrast material is not included in the radiological procedure and can be reported separately, typically with a HCPCS Level Il code to identify the substance used. The contrast material is reported by the facility, unless the procedure is performed in a physician’s office and the physician owns the equipment. 5

Chapter 17: Radiology The Radiology Report The radiologist’s written report is the documentation for the professional component of the radiological procedure and must be signed. Types of Radiological Services The Radiology section in the CPT* code book is divided into the following subsections: ¢ Diagnostic Radiology (Diagnostic Imaging) Procedures (70010-76499) ¢ Diagnostic Ultrasound Procedures (76506-76999) * Radiologic Guidance (77001-77022) o Breast, Mammography (77046-77067) * Bone/]oint Studies (7707 1-77092) ¢ Radiation Oncology Treatment (77261-77799) ¢ Nuclear Medicine Procedures (78012-79999) 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 as they are considered part of the basic procedure. In some instances, a screening film is used to detect an undiagnosed illness or condition. Screening films may be used to pre-diagnose or confirm a suspected condition. Comparison films are sometimes ordered to define the presence of an injury or pathology. Comparison films also may be ordered to pinpoint an abnormality or deformity between a normal and injured body part. Unless there is diagnosed pathology or injury in both areas, only the X-rays taken of the affected area are coded. Comparison of anatomical structures may be considered part of the physician’s medical decision-making process and final diagnosis. Diagnostic films may be required to evaluate the extent of the presenting symptoms or conditions or to track the progression of the patient’s condition or illness. Diabetic patients, or patients with poor wound healing potential, may have malunion or nonunion of a fractured bone. Careful X-ray monitoring is required to track the patient’s progress and customize a treatment plan relative to their healing potential. If splinting or casting is applied to a fracture, periodic films may be required to determine healing of the bone or maintenance of accurate alignment. Spot films are submitted for a radiologist’s interpretation when another physician performs the radiology supervision and interpretation procedure. Radiology supervision and interpretation codes require the radiologist to supervise performance of the procedure and provide a written interpretation of the procedure. If the radiologist was not present during the performance of the procedure, then he or she has not fulfilled the entire criteria for assigning an S&I code. To correctly report this scenario, the radiology code is appended with a modifier 52 Reduced Services, based on the lack of direct radiologist supervision. Even with a well-defined and carefully written interpretation, payers may not consider this service payable. PRACTICAL CODING NOTE Films that are unreadable, improperly positioned, or underdeveloped are considered operator error and not coded. Some technicians will make a note in the medical record for medicolegal documentation, but the patient should not be penalized when errors or omissions occur during the filming process. Portable, Handheld X-ray Device This low intensity X-ray imaging device is a lightweight portable handheld instrument using a low-level isotope as its penetrating energy source. It can picture any part of the human anatomy 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 departments. It is also useful in the instances where fluoroscopy would ordinarily be used, such as localization of foreign bodies, selected surgical procedures, and the evaluation of premature or low birth weight infants. Diagnostic Radiology (Diagnostic Imaging) Diagnostic radiology consists of X-rays, MRI, and CT scan studies. A plain X-ray is like taking a picture or snapshot of the inside of the body. The X-ray machine sends photons through the body with the film on the other side to record the images using ionizing radiation. Bone blocks the protons and appears white on the X-ray film, making it easy to discover a fractured bone. Contrast material also blocks the protons and shows white on the film. Structures containing air, such as lungs, appear black on X-ray images. Muscle, fat, and fluid appear as shades of gray. Such imaging allows initial diagnosis of many abnormalities within the body. Plain X-ray Although more and more radiology departments are replacing actual X-ray film with digital X-ray acquisition, the ultimate purpose is the same: to focus X-ray energy on a body part creating an image of a solid or dense internal structure. In medical practices today, an X-ray is used to diagnose and treat various problems. It is considered both a diagnostic and therapeutic tool. CT scans use a series of X-rays to produce cross-sectional pictures of the body. CT scans commonly are used to diagnose tumors, identify internal injuries caused by trauma, and to diagnose vascular disease. For instance, CTA, or computerized tomographic angiography, is a CT scan of the blood vessels. Computed Tomography (CT) Multiplanar diagnostic imaging (MPDI) combines data produced by CT scanning to create reconstructed oblique images that may contribute further diagnostic information. MPDI is also known as planar image reconstruction or reformatted imaging. According to CPT®, if radiographic arthrography is performed, use the arthrography supervision and interpretation code for the appropriate joint. Fluoroscopy is included in these codes. If CT or MRl is performed without radiographic arthrography, use the appropriate joint injection code, the accurate CT or an MRI code, and the correct imaging guidance code for needle placement for contrast injection. When an intrathecal injection is required, report 61055 or 62284. 6

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Chapter 17: Radiology Magnetic Resonance Imaging (MRI) An MRl is often used to diagnose conditions in a ligament, the brain, spinal cord, heart, and internal organs such as the lungs, liver, prostate, etc. An MRI produces slices of images by using a magnetic field and the protons within the body. The slices can be combined to produce 3-D images that may be viewed from different angles. This precise imaging helps physicians differentiate between healthy and unhealthy tissue. An MRI can assist in the differential diagnosis of mediastinal and retroperitoneal masses, including abnormalities of the large vessels such as aneurysms and dissection of vessels. When a clinical need exists to visualize the parenchyma of solid organs to detect anatomic disruption or neoplasia, this can be accomplished in the liver, urogenital system, adrenals, and pelvic organs without the use of radiological contrast materials. When an MRI is considered reasonable and necessary, the use of paramagnetic contrast materials may be covered as part of the study. An MRI may also be used to detect and stage pelvic and retroperitoneal neoplasms, evaluate disorders of cancellous bone and soft tissues, or detect pericardial thickening. Primary and secondary bone neoplasm and aseptic necrosis can be detected at an early stage and monitored with an MRL. Patients with metallic prostheses, especially of the hip, can be imaged to detect the early stages of infection of the bone to which the prosthesis is attached. An MRI may be performed with and without contrast. Magnetic resonance angiography (MRA) is an MRI of the blood vessels. MRA is a noninvasive diagnostic test and is an application of MRI. By analyzing the amount of energy released from tissues exposed to a strong magnetic field, an MRA provides images of normal and diseased blood vessels, as well as visualization and quantification of blood flow through these vessels. Phase contrast (PC) and time-of-flight (TOF) are the MRA techniques available at the time of publication. PC measures the difference between the phases of proton spins in tissue and blood and measures both the venous and arterial blood flow at any point in the cardiac cycle. The TOF measures the difference between the amount of magnetization of tissue and blood and provides information on the structure of blood vessels, indirectly indicating blood flow. Three-dimensional (3D) images can be obtained using this method. Contrast-enhanced MRA (CE-MRA) involves blood flow imaging after the patient receives an intravenous injection of a contrast agent. Gadolinium, a nonionic element, is the foundation of all contrast agents currently in use. Gadolinium affects the way in which tissues respond to magnetization, resulting in better visualization of structures when compared to unenhanced studies. Unlike ionic (for example, iodine-based) contrast agents used in conventional contrast angiography (CA), allergic reactions to gadolinium are extremely rare. Gadolinium does not cause kidney failure that is occasionally seen with ionic contrast agents. Physicians elect to use a specific MRA or CA technique based upon clinical information from each patient. Digital subtraction angiography (DSA) is a diagnostic imaging technique applying computer technology to fluoroscopy for visualizing the same vascular structures observable with conventional angiography. It is a computer-augmented form of CA, obtaining digital blood flow images as contrast agent courses through a blood vessel. The computer subtracts bone and other tissue from the image, improving visualization of blood vessels. Because the radiographic contrast material can be injected into a vein rather than an artery, the procedure reduces the risk to patients, and can be performed on an outpatient basis. When coding for diagnostic radiology, determine the anatomic location, the type of radiology used (X-ray, CT, MRI), the number of views, the type of views taken, and whether contrast material was used. To identify the location, break a word into word parts. Consider myelography as an example: Myel/o is the root word meaning spinal cord, and —graphy means the act of recording data. Myelography is recording data on the spinal cord. A myelography can be performed on different sections of the spinal cord and is coded according to the section studied. For example, a myelography of the cervical region is coded with CPT® code 72240. The myelography code is a supervision and interpretation code. Check if additional services need to be coded from other sections of the CPT® code book. Using the example of the cervical region, review the parenthetical instructions under CPT* code 72240 which states, “For complete cervical myelography via injection procedure at C1-C2 see 61055, 722407 When the anatomical location has been identified, codes for radiologic examination by X-ray often are selected based on the number of views. The number of views is not synonymous with the number of films used. A radiology technician may be required to shoot several films of the same view. The language used in CPT® refers to the number of views, not the number of films. (o i 571 1= 13 73560 Radiologic examination, knee; 1 or 2 views 73562 3views 73564 complete, 4 or more views The code descriptor may state a minimum number of views. When this terminology is used, the code includes any number of views in excess of the number provided in the description. For example, the description for CPT® code 73610 is Radiologic examination, ankle; complete, minimum of 3 views. Whether three, four, or more views are taken, 73610 is appropriate. For some radiologic examinations, the type of view taken, instead of the number of views, is the determining factor for code selection. When this is the case, if the physician only documents the number of views, there will be insufficient documentation for code selection. (o ipd 571 1= 13 72100 Radiologic examination, spin, lumbosacral; 2 or 3 views 72110 minimum of 4 views 72114 complete, including bending views, minimum of 6 views 72120 bending views only, 2 or 3 views Radiology codes by anatomical location are grouped together based on the type of imaging used (X-Ray, MR, CT, etc.). Upon finding the appropriate code, read the guidelines for that subsection of CPT®, along with any parenthetical notes listed below the code.

Chapter 17: Radiology Acronyms AP Anteroposterior CT Computed tormography CTA Computed tormography angiography KuB Kidneys, ureter, bladder LL Left lateral MRA Magnetic resonance angiography MRI Magnetic resonance imaging PA Posteroanterior Right lateral S&I Supervision and interpretation Temporomandibular joint Section Review 17.3 L. A contrast radiograph of the salivary glands and ducts is performed, resulting in a diagnosis of salivary fistula. What are the CPT* and ICD-10-CM codes for the supervision and interpretation of this procedure? A. 70380-26,K11.5 B. 70380-26,K11.3 C. 70390-26,K11.5 D. 70390-26,K11.4 Answer: . 70390-26,K11.4 Rationale: Contrast radiography of the salivary gland and ducts is considered sialography. Code 70390 describes sialography supervision and interpretation. Look in the CPT* Index for Salivary Glands/X-ray/with contrast. The patient is diagnosed with a salivary fistula, which is found in the ICD-10-CM Alphabetic Index under Fistula/salivary duct or gland K11.4. Verify code selection in the Tabular List. CT images of the abdomen and pelvis were obtained without IV contrast as a follow up to a splenic injury. Code the CT scan. A. 74019 B. 72170 C. 74176 D. 74170,72194 Answer: C. 74176 Rationale: Both CT of the abdomen and of the pelvis were obtained. There is one code to report for both anatomical areas taken at the same time. The “without contrast™ codes are used. Look in the CPT® Index for CT Scan/without Contrast/Abdomen or Pelvis. A parent brings a child to the Emergency Department after realizing the child swallowed a metal jack. A radiological exam from the nose to the rectum is performed. Code this service. A. 70160-26,70370-26, 71045-26, 74240-26, 74248-26 76010-26 B C. 70160-26, 70360-26, 71046-26, 74240-26, 74248-26 D. 70160-26,70370-26, 74240-26, 74248-26 Answer: B. 76010-26 Rationale: Look in the CPT® Index for X-ray/Nose to Rectum/Foreign Body 76010. Turning to 76010 in the numeric section, this code is applicable to a child for a single view.

Chapter 17: Radiology 4. A patient presents to her physician with right eye pain, nasal airway obstruction, and deformity 48 hours after an assault. The physician orders an X-ray of the facial bones with a Waters view, Caldwell view, and a lateral view. What is the CPT® code for the X-ray? A. 70486 B. 70220 C. 70150 D. 70140 l Hide Answer 2 I Answer: C. 70150 Rationale: Three views of the facial bones (Waters’ view, Caldwell view, and lateral view) were ordered. Look in the CPT* Index for X-ray/Facial Bones, 70140-70150. Code 70150 is for a complete, minimum of three views X-ray of the facial bones. 5. A patient presents to the physician with stiffness and numbness in the neck, shoulders, and arms. The physician orders an MRI of the cervical spine, without and with contrast, to rule out cervical spinal stenosis. Code the MRL A. 72020 B. 72127 C. 72141,72142 D. 72156 [Hide Answer ] Answer: ). 72156 Rationale: Look in the CPT* Index for Magnetic Resonance Imaging (MRI)/Diagnostic/Spine/Cervical, 72141-72142, and 72156. Because both without contrast and with contrast were used for this cervical MRI, CPT® code 72156 is selected. Diagnostic Ultrasound Diagnostic ultrasound uses sound waves to visualize internal structures such as muscles, tendons, and organs. The images then can be used to measure the size and observe the movement and functionality of structures such as the heart or blood vessels. During pregnancy ultrasound is used to view the fetus. Ultrasound is also used for guidance in various procedures. There are different types of ultrasound scans. Some types include A-mode (A-scan); B-mode (B-scan); M-mode; and Real-time scan. A-mode (amplitude mode) is a one-dimensional scan typically only seen in ophthalmic ultrasounds. B-mode (brightness mode) is a two-dimensional scan. M-mode (motion mode) is a one-dimensional scan showing the movement of a moving structure (such as the heart). Real-time scans are B-scans in motion. Also available are 3-D and 4-D scans, which are 3-D ultrasounds in motion. It's necessary to understand the different types of scans to select the correct code. A Doppler study is a type of ultrasound penetrating solids or liquids. This type of study is useful in imaging the flow of blood. The Doppler can create images either in shades of gray or when processed by a computer, color images. The use of Doppler imaging is separately reportable, except when used alone for anatomic structure identification with real-time ultrasound. To report a Doppler study there must be a permanent record of the images and a written report. In the Head and Neck anatomical subsection, there are different types of scans for ophthalmic ultrasounds such as a biometric A-scan, biomicroscopy, quantitative A-scan, biomicroscopy, quantative A-scan, and corneal pachymetry. For an A-scan, the patient looks straight ahead. For a B-scan, the patient looks in many different directions. A biomicroscopy is a slit lamp exam, which is a low-power microscope combined with a high-intensity light source focused to shine in a thin beam. This test may detect cataracts, macular degeneration, retinal detachment, and other eye diseases. A comeal pachymetry is a test to determine corneal thickness. Topical anesthesia is required for comeal pachymetry because the probe must touch the comeal surface. Corneal pachymetry is one of the biometric studies not requiring permanently recorded images. Some anatomic regions have complete and limited ultrasound codes. Elements comprising a complete exam are listed in the code description in parentheses. For example, the guidelines in the abdomen and retroperitoneum subsection give the definitions of a complete ultrasound exam for the abdomen and the retroperitoneum. The abdomen real-time scan includes the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. If the intent of the procedure is to visualize all of these, but one is obstructed from view, the physician must document why he or she was not able to visualize the organ or structure. If less than a complete exam is performed, report the limited ultrasound code. Pelvic ultrasounds are divided further between obstetric (76801-76828) and nonobstetric (76830-76857). An obstetric ultrasound is either a pregnant uterus ultrasound or a fetal ultrasound. The components of each pregnant uterus ultrasound are listed within the guidelines of the obstetrical pelvis subsection. The fetal ultrasounds differ according to what is evaluated. Fetal ultrasounds include a biophysical profile (BPP) examining the health of the fetus, including information on the amniotic fluid, fetal breathing, fetal tone, and gross body movements. This profile can be performed with or without nonstress testing. Nonobstetric ultrasounds include a transvaginal ultrasound, a sonohysterography, and nonobstetric pelvic ultrasounds. A transvaginal (through the vagina) ultrasound is used to look at the female reproductive organs—the uterus, ovaries, cervix, and vagina—to search for ovarian cysts, tumors, infection, etc. Transvaginal ultrasound is also used in obstetrics early in pregnancy and to evaluate the cervix. Sonohysterography is an ultrasound of the uterus. Saline infusion sonohysterography occurs when sterile saline is introduced into the uterus through the cervix. The procedure is used to evaluate symptoms such as abnormal uterine bleeding, infertility, or abnormalities of the uterine lining. More information about the nonobstetrical pelvic ultrasound codes can be found in the guidelines in the CPT® code book.

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Chapter 17: Radiology Ultrasonic guidance codes are selected based on the type of procedure performed (such as, pericardiocentesis, vascular access, needle placement, etc.). During an encounter, either a diagnostic ultrasound code or an ultrasound guidance code may be reported, but not both. Radiologic Guidance As with ultrasound guidance, services classified as radiologic guidance are used to help the provider see inside the body as he or she is performing noninvasive or percutaneous procedures. The radiologic guidance codes are organized by the type of radiological guidance used—whether it is fluoroscopic, CI, MRI, or another type of guidance—and selected based on the precise procedure performed. Fluoroscopy is a continuous X-ray displayed onto a screen for monitoring. The continuous image is used like a real-time movie to view the movement of a body part, or of an instrument or dye moving through the body. Fluoroscopic guidance codes are used for catheter insertion, needle placement, and localization of a needle or catheter. Like fluoroscopy, CT allows the physician to view a constant image on a screen to monitor the movements made within the body. It often is used in the treatment of tumors. CT- guided stereotactic localization is used to make sure radiation beams are targeting the tumor instead of surrounding tissue or other vital organs. A CT also can be used to assist monitoring parenchymal tissue ablation and the placement of radiation therapy fields. Parenchyma is the functional tissue of an organ. Parenchymal tissue ablation is destruction of the parenchymal tissue containing the cancerous cells. MRl may be used for needle placement and parenchymal tissue ablation as well. Breast, Mammography Mammography is an X-ray of the breast using special equipment. It has been the long-standing tool for screening and diagnosing breast disease. Mammography codes are selected based on the imaging device, procedure performed, whether it is screening or diagnostic, and whether it is unilateral or bilateral. Screening mammogram is often used to detect breast cancer. The National Cancer Institute recommends women age 50 and over have a screening mammogram every one to two years, or more frequently for those at high-risk. A screening mammogram is performed when no symptoms exist and typically takes less time than a diagnostic mammogram. Screening mammogram codes are considered bilateral. Diagnostic mammograms focus on a symptom and may be unilateral or bilateral. The radiology technician may need to focus on a specific area to get a better view of a suspected problem. Diagnostic mammograms also may be combined with software using computer algorithm analysis designed to help the radiologist interpret mammograms. When this software is used, it is considered computer-aided detection (CAD) and is included with the mammogram. Digital breast tomosynthesis takes multiple images of the breast and produces a 3-D image of the breast. This provides a clearer image of the breast. There are codes for unilateral or bilateral diagnostic digital breast tomosynthesis and an add-on code for screening tomosynthesis during a screening mammogram. A ductogram or galactogram (galact- is a root word meaning milk), is imaging of the ducts in the breast. It typically is used to find the reason for nipple discharge. Additional studies found in this section include MRI of the breast. Mammography with CAD Reason for Exam: Lump in axillary tail of right breast, history of breast cancer at age 73. Ordered: MAMMOGRAPHY, DIGITAL, BILATERAL Report: Bilateral CC, MLO, and XCCL views were taken. Impression: The breast tissue is heterogeneously dense. This may lower the sensitivity of mammography. There are no dominant masses or suspicious calcifications. There is architectural distortion and increased density in the upper outer left breast consistent with post-operative and post radiation changes. Assessment: Bi-RADS 2: BENIGN FINDINGS Recommendation: Routine screening mammogram This examination was reviewed with the aid of R2 Image Checker Computer Aided Detection, Version 9.0. CPT* Code: 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral ICD-10-CM codes: N63.31 Unspecified lump in axillary tail of the right breast, R92.323 Mammographic fibroglandular density, bilateral breasts, 785.3 Personal history of malignant neoplasm of breast. In this case, indications confirm a diagnostic mammography is reported. The mammography was performed bilaterally. Although the recommendation states “routine screening mammography” this is a recommendation, not the type of procedure. The patient had a lump in her right breast, thereby indicating the need for a diagnostic mammogram. Finally, documentation states the mammography was performed with CAD. Section Review 174 1. During a physical examination hepatomegaly is revealed. The physician orders an ultrasound of the liver to evaluate the hepatomegaly. What CPT* code is reported? A. 74018 B. 76705 C. 74022 D. 76700 Answer: B. 76705 Rationale: Ultrasound of the abdomen includes the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. Because the ultrasound was of only the liver, it is considered a limited abdominal ultrasound. Look in the CPT* Index for Ultrasound/Abdomen. 10

Chapter 17: Radiology 2. A patient 20 weeks pregnant with twins goes to her OB/GYN for an ultrasound to check the position of both fetuses. Code the ultrasound. 76805,76810 = 76816 C. 76816,76810 D. 76815 Answer: D. 76815 Rationale: The ultrasound is limited because the position of the fetuses is all that the ultrasound is verifying. Look in the CPT® Index for Ultrasound/Obstetrical/Pregnant Uterus. The description of 76815 includes one or more fetuses and the code is reported once only. 3. A complete B-scan ultrasound without duplex Doppler of the kidney is performed in the physician’s office on a patient following a kidney transplant. What is the CPT® code for the ultrasound? A. 76705 B. 76775 C. 76776 D 76811 Answer: B. 76775 Rationale: Look in the CPT® Index for Ultrasound/Kidney, 76770-76776. CPT® code 76776 is an ultrasound for a transplanted kidney, including real-time and duplex Doppler with image documentation. A duplex Doppler of the kidney is not performed. The parenthetical instruction under CPT* 76776 indicates to report 76775 for an ultrasound of transplanted kidney without duplex Doppler. The correct code is 76775. 4. A patient with left breast pain and a lump in the breast visits her physician. After examination, the physician orders a mammogram of the left breast. The mammography is performed using computer-aided detection software. Code the mammography. A. 77066 B. 77067 C. 77065 D. 77061 Hide Answer » Answer: C. 77065 Rationale: The physician ordered a unilateral diagnostic mammogram with computer-aided detection (CAD). Code 77065 describes a diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral. The use of ultrasound to examine and measure internal structures of the skull and to diagnose abnormalities and disease is echoencephalography. What is the code for echoencephalography and/or real time with image documentation, including A-mode encephalography as a secondary component where indicated? A. 76506 B. 76510 C. 76511 D. 76512 Answer: A. 76506 Rationale: An echoencephalography is performed to identify any abnormalities or disease(s). Look in the CPT*Index for Echoencephalography/Intracranial, code 76506. Bone/Joint Studies Bone and joint studies are performed to determine bone or joint abnormalities—whether the abnormality is the length of the bone, age of the bone, composition of the bone, or how the joint moves when stress is applied. A bone age study is typically performed on children to estimate the maturity of a child’s skeletal system, based on the appearance of the growth plate in the bone. A bone length study is used to determine discrepancies in limb length. Osseous surveys are radiological procedures used to detect fractures, tumors, or degenerative conditions of the bone. Osseous surveys are coded based on whether the service is limited or complete, or if the survey was performed on an infant. Dual-energy X-ray absorptiometry (DXA or DEXA), is a common test performed to determine bone density. This test helps to evaluate risk of bone fractures (which often are the result of osteoporosis). DEXA scans are coded based on the location of the body part being scanned. A trabecular bone score study measures the structure of the bone and is used to evaluate fracture risk. 11

Chapter 17: Radiology Radiation Oncology Radiation oncology is a multi-disciplinary medical specialty involving physicians, physicists and dosimetrists, nurses, biomedical scientists, computer scientists, radiotherapy technologists, nutritionists, and social workers. It is a highly specialized and complex method for delivering radiation treatment to tumors. The radiation oncology subsection in the CPT*® code book is divided into subheadings: » Consultation: Clinical Management for Radiation Treatment * (linical Treatment Planning (External and Internal Sources) * Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services for Radiation Treatment » Stereotactic Radiation Treatment Delivery e Other Procedures ¢ Radiation Treatment Delivery e Neutron Beam Treatment Delivery * Radiation Treatment Management * Proton Beam Radiation Treatment Delivery » Radiation Hyperthermia Treatment » (linical Intracavitary Radiation Hyperthermia Treatment e (linical Brachytherapy Radiation Treatment When a patient first visits the radiation oncologist, there is a consultation to determine if radiation will benefit the patient. According to CPT®, this service is reported from the appropriate evaluation and management, medicine, or surgical codes. After the initial consultation, the patient and provider plan the treatment. Clinical treatment planning is how the provider determines the ports, blocks, and doses of radiation. According to CPT* guidelines, clinical treatment planning involves interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of the number and size of treatment ports, selection of appropriate treatment devices, and other procedures. The appropriate code (77261-77263) is based on the level of planning: simple, intermediate, or complex. Planning levels are defined by the number of treatment areas, ports, and blocks; consideration of special dose time; and if rotational or special beams are required. The definitions for simple, intermediate, and complex are found in the crr® guidelines. A port is the place where radiation enters the body and is often marked with tattooing. Blocks are special pieces of lead designed specifically for each patient to shield healthy normal tissue from receiving the radiation allowing the radiation to focus solely on the tumor. During the treatment planning process, the provider and patient go through simulation. Simulation may be carried out on a dedicated simulator, a radiation therapy treatment unit, or diagnostic X-ray machine. The provider must be present. The therapeutic radiology simulation-aided field setting codes are used for this procedure (77280-77299). This process requires the patient to lie very still on a table while the provider determines the port entry. The simulation is selected based on the number of ports, blocks, and the use of contrast material, and 3-D simulation. The information gained in simulation is then sent to medical radiation physicists and medical radiation dosimetrists. Dosimetry is the calculation of the dose of radiation. These highly-trained physicians design and create the blocks to shield the healthy tissue. They also plan the dose delivery. The services of the physicists and dosimetrists are reported using the codes in the subsection for Medical Radiation Physics, Dosimetry, Treatment Devices and Special Planning (77295, 77300-77370). Radiation Treatment Management The actual delivery of radiation is reported by the facility. The oversight of the delivery is reported by the physician (77427-77499), which includes review of the port images, dosimetry, dose delivery, treatment parameters, and treatment set up. This oversight is considered radiation treatment management, and is reported by the number of fractions. Patients typically receive radiation treatment in fractions. The treatment itself is quick and only takes a matter of minutes, but is delivered frequently, including daily or twice per day. When the delivery is twice per day, it is considered two fractions as there is a distinct break in therapy. This phase of treatment is reported in units of five fractions or treatment sessions, regardless of the actual time-period in which the services are furnished. The services need not be furnished on consecutive days. Code 77427 is also reported for 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. CPT*® 77470 reports the physician’s work necessary for the management of special procedures such as total body irradiation, combination with chemotherapy, or other combined modality therapy, stereotactic radiosurgery, and intraoperative radiation therapy. Stereotactic, Radiation Treatment Delivery, Neutron Beam, and Proton Beam Treatment Delivery The treatment delivery sections reported by the facility only include the following Radiation Oncology subsections: ¢ Stereotactic Radiation Treatment Delivery ¢ Radiation Treatment Delivery (except for the stereoscopic guidance) ¢ Neutron Beam Treatment Delivery ¢ Proton Beam Treatment Delivery Stereotactic Radiation Treatment Delivery (77371-77373) Stereotactic radiation treatment is also called radiation surgery, radiosurgery, stereotactic external-beam radiation, and stereotactic radiosurgery. Although it is not actual surgery, it involves precise positioning by use of special equipment to deliver large radiation doses to tumors in the brain and not to normal tissue. It is also used to treat other brain disorders and is being studied in the treatment of lung and other types of cancer. Radiation Treatment Delivery (77385-77425) Code 77387 reports guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking when performed. Neutron Beam Treatment Delivery (77423) Code 77423 describes high-energy neutron radiation treatment delivery to one or more isocenter(s) with coplanar or noncoplanar geometry with blocking and wedge and/or compensator(s). 12

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Chapter 17: Radiology Proton Beam Treatment Delivery (77520-77525) Proton treatment delivery uses protons (positively charged particles) to target tumors in sensitive areas. Because of the physical makeup of protons, they release most of their energy when they hit the tumor, and do not pass beyond the tumor. Proton treatment delivery is used for lung, brain, prostate tumors, and tumors in pediatric patients. Code selection is based on the number of ports and blocks used. Bracket the codes reported by the facility only, and label as *facility only” These codes do not need modifier 26 or TC appended to them: 77336; 77371-77373; 77401-77417; 77385-77386; 77423; 7T7T424-T7425; 77520-77525. Hyperthermia Hyperthermia is the use of heat as an adjunct to radiation therapy or chemotherapy to make some cancer cells more sensitive to radiation or to chemotherapy. Hyperthermia used with radiation therapy is under investigation. The heat source may be microwave, ultrasound, low-energy radiofrequency conduction, or by probe. Hyperthermia is used to bring body tissue and cancer cells to excessive heat levels (up to 113°F). The excessive heat can damage and weaken the cancer cells, allowing them to be more susceptible to the radiation or even destroying them. Some payers currently only allow for deep hyperthermia and some do not allow hyperthermia at all. Review payer contracts and guidelines to determine if hyperthermia is reimbursable. Clinical Brachytherapy Clinical brachytherapy uses radioactive material sealed in needles, seeds, wires, or catheters. The sealed radioactive material is placed in or near a tumor. This may also be referred to as an internal or implant radiation therapy. Interstitial brachytherapy is when seeds or other sealed radioactive material are inserted into tissue at or near the tumor site. Intracavitary brachytherapy is when it is inserted into a body cavity with an applicator. Remote High dose-rate (HDR) afterloading brachytherapy involves the precise insertion of catheters into the tumor. The catheter(s) is then connected to a remote afterloading brachytherapy unit, which delivers radiation. Nuclear Medicine Nuclear medicine is the use of small amounts of radioactive material to examine organ function and structure. Therapeutic nuclear medicine can be used to treat cancer and other medical conditions. The radiopharmaceuticals used in nuclear medicine are not included in the coding of the tests and should be reported separately, typically using a HCPCS Level I code by the facility. The radiopharmaceuticals, or radiotracers, can be swallowed, inhaled, or injected into a vein. A gamma camera, a PET scan, or a probe is used to detect the radioactive material. PET, SPECT A Positron Emission Tomography (PET) is a noninvasive diagnostic imaging procedure assessing 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, which are obtained from positron emitting radioactive tracer substances (radiopharmaceuticals) such as 2-[F-18] Fluoro-D-Glucose (FDG), administered intravenously to the patient. A Single Photon Emission Computed Tomography (SPECT) acquires information on the concentration of radionuclides introduced into the patient’s body. It is useful in the diagnosis of several clinical conditions including: stress fracture, spondylosis, infection (for example, discitis), tumor (for example, osteoid osteoma), analysis of blood flow to an organ, asin the case of myocardial viability, and to differentiate ischemic heart disease from dilated cardiomyopathy. 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. When vascular flow studies are obtained using planar technology in addition to SPECT studies, the appropriate CPT* code for the vascular flow study should be reported, not the flow, planar and SPECT studies. In cases where planar images are procured because of the extent of the scanned area (for example, bone imaging), both planar and SPECT scans may be necessary and reported separately. Absorptiometry Single photon absorptiometry (CPT* 78350), also known as a bone density (bone mineral content) study, describes a noninvasive radiological technique that measures the absorption of a monochromatic or dichromatic photon beam by bone material in one or more sites. The device, which is placed directly on the patient, uses a low dose of radionuclide to measure the mass absorption efficiency of the energy released. The exam provides a quantitative measurement of the bone mineral of cortical and trabecular bone 10 assess treatment response at appropriate intervals. Dual photon absorptiometry (CPT* 78351) is a noninvasive radiological technique measuring absorption of a mono- or dichromatic beam by bone material in one or more sites. This procedure is not covered under Medicare because it is still considered to be in the investigational stage. Pulmonary Perfusion Imaging CPT® 78597-78598 report the imaging of 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 perfusion. This procedure is used in the diagnosis of pulmonary embolism, bronchopulmonary sequestration, and pulmonary trauma. Other Procedures (78800-78999) Nuclear diagnostic imaging is an imaging technique that uses a radioactive substance or tracer to diagnose and treat disease. Imaging one specific body area, such as the chest, through the infusion of labeled indium-111 antibody to diagnose and localize the tumor tissue in a single day is reported with code 78800. If two or more body areas are imaged, such as the head and chest, in one or more days, or one single body area where the imaging is over two or more days, report code 78801. Nuclear medicine codes 78802 and 78804 report the scanning or imaging of the whole body. Report code 78802 for imaging studies of the whole body performed on a single day and 78804 for the whole body performed on two or more days. Image interpretation requires qualitative assessment of blood clearance, normal uptake by kidneys and lungs, and uptake within tumor. SPECT tumor imaging studies are reported with codes 78803 and 78830-78832. Codes 78811-78816 differentiate the three different levels of work associated with PET and PET/CT imaging. Code 78811 is a limited PET study (eg, chest, head/neck); code 78812 describes a PET study of the skull base to mid-thigh; and code 78813 reports a PET study of the whole body. Code 78814 describes a PET procedure with concurrently acquired CT for attenuation correction and anatomical localization of a limited area. Code 78815 reports a study using PET with concurrently acquired CT for attenuation correction and anatomical localization of the skull base to mid-thigh, and code 78816 refers to a whole body study using PET with concurrently acquired CT for attenuation correction and anatomical localization. 13

Chapter 17: Radiology PRACTICAL CODING NOTE For code series 78814-78816, if a diagnostic CT is performed for other than attenuation correction and anatomical localization concurrently with the PET study, use modifier 59 with the appropriate site-specific CT codes. There must be a separate order for the diagnostic CT and for the PET or CT performed for attenuation or anatomical localization. Therapeutic (79005-79999) Radiolabeled monoclonal antibodies (CPT® code 79403) can locate tumor cells and either kill them or deliver tumor-killing substances to them without harming normal cells. Monoclonal antibodies (mAb) of murine origin can target tumors and detect disease when labeled with radionuclides that emit gamma rays. Satumomab pendetide (OncoScint CR/OV) labeled with indium-111 has been approved by the FDA for the single-use detection of extrahepatic intra-abdominal metastases from colorectal or ovarian cancer. Report code 78802 or 78804 for pre-treatment imaging. PRACTICAL CODING NOTE The oral and intravenous administration codes in this section include the mode of administration. For intra-arterial, intracavitary and intra-articular administration, use the appropriate injection and/or procedure codes, as well as imaging guidance and radiological supervision and interpretation codes. Code 79005 was established to report radiopharmaceutical therapy by oral administration; code 79101 was established to report radiopharmaceutical therapy by intravenous administration. Pay attention to the parenthetical notes referring to code 79101. Code 79445 reports radiopharmaceutical therapy by intra-arterial particulate administration; report a HCPCS Level 11 code for the use of therapeutic radiopharmaceuticals. When the services are performed in a facility, the facility reports the radiopharmaceuticals. Codes 79200, 79300, and 79440 indicate route of administration (intracavitary, interstitial and intra-articular). Nuclear medicine codes are selected based on the test performed. HCPCS Level I A HCPCS Level 1l code exists for a PET scan. Whole body PET scans may be used for staging melanoma. When a Medicare patient receives a PET scan for melanoma without the specified indications covered by Medicare, the service is reported using a HCPCS Level Il code. HCPCS LEVEL | EXAMPLE G0219 PET imaging whole body; melanoma for noncovered indications During MRI or CT scans, contrast material may be used. The contrast material clarifies soft tissue during the scan. When contrast material is used, a HCPCS Level Il code can be reported in addition to the scan. When the services are performed in a facility, the facility reports the radiopharmaceuticals. Modifiers The two most common modifiers used with radiological services are: * 26 Professional Component e TC Technical Component To evaluate the total cost of a radiology service, the equipment, overhead, technician cost, and the radiologist are considered. Radiology services can be performed in the hospital, provider’s office, or an independent radiology center. To make sure both the facility and radiologist are paid for their services, the radiology services can be split into the professional and technical components. The cost of the equipment, overhead of the supplies, and resources such as the room, electricity, and the salary of the radiology technician, are all included in the technical component. The technical component is reported by the facility or office that owns the equipment. Patients receiving MRI, CT, PET scans, or more advanced radiological procedures typically are sent to the hospital or independent diagnostic testing facility (IDTF) for the service. When a service is performed in a hospital, the hospital has the overhead of the equipment, supplies, and radiology technician. In this case, the hospital bills for the technical component. To report the technical component, modifier TC is appended to the CPT® code from the radiology section. After the radiology procedure is performed, it must be read (interpreted) by a physician or other qualified practitioner. The provider’s specialty can be radiology, but it is not required to code for the service(s). The interpretation and report of the radiological service is considered the professional component. When a patient has a radiology service in the hospital, but a radiologist independent of the hospital reads or interprets the radiology service, the radiologist reports the professional service. To report the professional component, modifier 26 is appended to the CPT® code from the radiology section. A facility owning the equipment and employing the radiologist would bill for both the technical and professional component. Both components together are considered global. Sometimes, a physician’s office will own the equipment, read the X-ray, and provide the report. An example of this is an orthopedic office with X-ray equipment. When the office owns the equipment, has the overhead cost of the procedure, reads the X-ray, and provides the report, the office bills the global procedure. A global procedure is reported using the correct CPT® code without a modifier appended. Example cost structure for professional and technical components: 72040 Radiographic examination, spine, cervical; 2 or 3 views CPT“Code TC 26 Global 72040 $29.48 $10.84 $4033 *Fees are based on the 2023 National Medicare Physician Fee Schedule. Additional modifiers applicable to radiological procedures include: 76—Repeat Procedure or Service by Same Physician or Other Qualified Healthcare Professional 77—Repeat Procedure or Service by Another Physician or Other Qualified Healthcare Professional 79—Unrelated Procedure or Service by the Same Physician or Other Qualified Healthcare Professional During the Postoperative Period RT—Right side (used to identify procedures performed on the right side of the body) LT—Left side (used to identify procedures performed on the left side of the body) 14

Chapter 17: Radiology Section Review 17.5 A patient receives complex radiation oncology treatments two times a day for three days. Code this series of clinical management fractions. A. 77427x3,77431x3 B. 77427 C. 77525x3,77523x3 D. 77427 77431 Answer: B. 77427 Rationale: Radiation therapy management is based on the number of fractions. Each time the patient receives the radiation is considered a fraction. If the patient receives radiation two times in one day, it is considered two fractions. This patient had a total of 6 fractions of radiation. Code 77427 indicates five fractions. According to the radiation treatment management guidelines, when a patient has one or two fractions left at the end of a course of treatment, it is not separately billable. Code 77431 is used when the entire course of treatment consists of only 1 or 2 fractions. The correct code to report for the management is 77427. Look in the CPT* Index for Radiation Therapy/Treatment Management/Weekly. 2. A DXA body composition study is performed on a patient. Code the scan. A. 77080,77081 B. 77080 C. 77086 D. 76499 Answer: D. 76499 Rationale: Dual energy X-ray absorptiometry (DXA) studies are indexed under Dual X-ray Absorptiometry (DXA) in the code range 77080-77086. Under 77081 isa parenthetical instruction stating to use 76499 for a DXA body composition study. 3. A male patient being treated for prostate cancer receives brachytherapy treatment. Twelve radioactive seeds are interstitially applied within the prostate. What is the CPT® code for the radiological component? A. 0395T B. 77778 C. 77771 D. 77789 Answer: B. 77778 Rationale: In this case, brachytherapy is performed using interstitial application of radiation seeds. According to the Radiology Guidelines, a complex application has greater than 10 sources, which is reported with code 77778. Review the CPT* coding guidelines for the definition of simple, intermediate, and complex for clinical brachytherapy. Look in the CPT® Index for Brachytherapy/Interstitial Application 0395T, 77778. 4. Patient is in the orthopedist office with an injured ankle. The orthopedist thinks it is only a sprained ankle but decides to take an ankle X-ray to rule out a fracture. A two-view ankle X-ray is taken in the physician’s office. The orthopedist reviews the ankle X-ray and it is negative for a fracture. The report is placed in the medical record. How is the X- ray reported by the orthopedist? A. 73600-26 B. 73600-TC C. 73600-26-TC D. 73600 Hide Answer » Answer: D. 73600 Rationale: In this case, no modifiers are reported with the CPT*® code; you report the global procedure. Because the ankle X-ray was taken in the physician’s office (meaning the office owns the equipment) and the physician reads the X-ray and provides a report, the CPT® code is reported without a modifier. The global service 73600 includes both the professional and technical components. L7 A patient with osteoporosis reports to her physician’s office for a DXA bone density study of her spine to monitor the severity of her condition. What is the correct CPT* code for the DXA scan? A. 77080 B. 77081 C. 77086 D. 77081-52 Answer: A. 77080 Rationale: DXA is dual-energy X-ray absorption. The site is of the spine, which is part of the axial skeleton. In the CPT* Index, look for DXA and you are directed to see Dual X-ray Absorptiometry (DXA); Dual X-ray Absorptiometry (DXA)/Axial Skeleton. In this case, one site (spine) is involved in the study. The correct code is 77080. 15

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Chapter 17: Radiology DOCUMENTATION DISSECTION CASE 1 Tunneled Dialysis Catheter Placement Clinical History: A 60-year-old female patient presents with end-stage renal disease. " Infected right internal jugular dual-lumen dialysis catheter removed 9/2/20XX. Technique: Informed consent was obtained. The patient was identified and placed in the supine position. The right internal jugular vein was examined with ultrasound 2 and found to be compressible, with a partial thrombus, likely secondary to prior catheter. An image was recorded and placed in the medical record. The right side of the neck and chest was prepped and draped in the usual sterile fashion. 1% Lidocaine with epinephrine local anesthesia was administered. Under ultrasound guidance 5 and using a micropuncture needle, the right internal jugular vein was accessed and a guidewire passed. The needle was exchanged for the micropuncture introducer/sheath. A subcutaneous tunnel ® was developed over the chest wall connecting to the puncture site in the neck. Under fluoroscopic observation, = a 23 cm tip to cuff double lumen Duro- flow catheter, after being advanced through the subcutaneous tunnel, was passed into the right internal jugular vein via a peel-away sheath. The catheter tip was placed in the right atrium. * Both ports had good forward flush and return. The catheter was sutured at the skin exit site and it was flushed with heparinized saline. The incision in the neck was closed with Dermabond. The patient tolerated the procedure well and the procedure was without complications. Dr. Wilson, the interventional radiologist performed the entire procedure and reviewed and interpreted all images obtained. 4 Impression: Uncomplicated placement of a right internal jugular vein, 23 cm tip to cuff, double lumen tunneled catheter. H'The patient has ESRD. E Ultrasound was utilized for catheter placement. El Ultrasound guidance noted again. E The catheter was tunneled. Bl Fluoroscopic gnidance was used. 5 The catheter was tunneled from the right internal jugular vein to the right atrium. Y'The interventional radiologists performed the procedure and reviewed and interpreted all of the images for the ultrasound guidance and fluoroscopic guidance. What are the CPT* and ICD-10-CM codes reported? CPT" codes: 36558, 76937-26, 77001-26 ICD-10-CM codes: 749.01, N18.6 Rationale: The documentation indicates the use of ultrasound guidance and additional use of fluoroscopic guidance. Look in the CPT® Index under Central Venous Catheter Placement/Insertion/Central/Tunneled without port or pump 36557-36558, 36565. Venous access is in the CPT*® Index under Ultrasound/Guidance/Vascular Access 76937. Modifier 26 is appended for the professional service. Look in the CPT® Index for Venous Access Device/Fluoroscopic Guidance 77001. Modifier 26 is appended for the professional service. ICD-10-CM codes: The patient is being seen for replacement of a dialysis catheter previously removed. Look in the ICD-10-CM Alphabetic Index for Management (of )/renal dialysis catheter Z49.01, or for Preparatory care for subsequent treatment NEC/for dialysis Z49.01. Category 749 has a note to code also any associated end stage renal disease, N18.6. Verify the codes in the Tabular List. 16

Chapter 17: Radiology CASE 2 Abdominal CT without Contrast Performed at Outpatient Diagnostic Center Indication: Follow-up splenic injury & Comparison: Archived images of outside CT of the abdomen and pelvis ¥ from 2:40 p.m. on August 12, 2016 Technique: MDCT images of the abdomen and pelvis were obtained without IV contrast. & Findings: There is limited visualization due to lack of IV contrast. However, when compared to the prior exam, there is no significant change in the overall size of the parenchymal laceration/hematoma ¥ associated with the left spleen. This suggests there has not been significant bleeding in the interim. Multiple focal areas of mildly increased attenuation within the splenic parenchyma correspond with areas of focal hematoma/contrast pooling seen on the prior study. This may be related to evolution of clot formation within the laceration. Stable amount of fluid noted adjacent to the liver. This has lower Hounsfield units than the blood that is seen around the spleen. There is some residual contrast in the renal collecting systems and bladder. The bladder appears grossly intact. Small amount of fluid in the pelvis. Right flank subcutaneous tissue edema consistent with contusion/ecchymosis. The IVC is flat, consistent with volume depletion. Scattered atherosclerotic calcifications of the aorta. No evidence of free intra-abdominal air. Moderate degenerative changes of the visualized spine. Dependent atelectasis in the bilateral lung bases. No visualized displaced rib fractures. There are multilevel degenerative changes of the spine. No evidence of acute fracture of the lower thoracic or lumbar spine on axial, sagittal, or coronal images. Fat filled left inguinal canal is noted. Impression: 1. Grossly stable size of 2 cm parenchymal laceration of the left spleen = as compared to outside exam. Evaluation is limited due to lack of IV contrast. There is also blood layering around the liver. This is likely due to the splenic injury. 2. Volume plasma depletion ™ as evidenced by small caliber of the inferior vena cava. 3. No definite evidence of acute fracture of the lower thoracic or lumbar spine. X Reason for the CT. EICT of the abdomen and of the pelvis were performed. Bl CTs were without contrast. B There is a parenchymal laceration, which is significant in the ICD-10-CM coding. ! Primary diagnosis. ¥ Secondary diagnosis. Y Volume depletion indicated by the inferior vena cava indicates a volume depletion of plasma in the blood (hypovolemia). What are the CPT* and ICD-10-CM codes reported? CPT* codes: 74176-26 ICD-10-CM codes: S36.031D, E86.1 Rationale: The exam was CT (computed tomography), without contrast. The abdomen and pelvis were examined. The report indicates that a CT of both the abdomen and pelvis were performed without contrast. Look in the CPT® Index under CT Scan/without Contrast/Abdomen or Pelvis. Code 74176 reports the CT abdomen and pelvis, without contrast. Modifier 26 is used to indicate the professional portion of the CT. ICD-10-CM codes: Look in the ICD-10-CM Alphabetic Index for Laceration/spleen/moderate S36.031-. Verify the code in the Tabular List. In the Tabular List, there is a note under S36.031 that indicates a moderate laceration is 1-3 cm. This laceration is 2 cm, making this the correct code selection. Code S36.031 requires a 7" character. This is a follow-up study, making D for subsequent encounter the correct 7" character. Volume plasma depletion is also coded. Look in the ICD-10-CM Alphabetic Index for Depletion/plasma or Hypovolemia referring you to E86.1. Verify the code in the Tabular List. Glossary Angiography—Radiographic image of the blood vessels, using contrast material. Aortography—Radiographic image of the aorta and branches, using contrast material. Atherectomy—To remove plaque from an artery. Brachytherapy—Radiation placed in or near a tumor within the body. Catheters, needles, seeds or wires may be used. Bronchography—Radiographic image of the bronchi of the lungs, using contrast material. Cephalogram—Radiographic image of the head. Cholangiography—Radiographic image of the bile duct. Cineradiography—Radiography of an organ in motion (for example, a beating heart). Colonography—Radiographic image of the (interior) colon. Computed Tomography (CT)—Using specialized equipment, two-dimensional X-ray images are taken around a single axis of rotation. The images are combined to create a three- dimensional image or pictures of the inside of the body. These cross-sectional images of the area being studied may be examined on a computer monitor, printed or transferred to a CD. Corpora Cavernosography—Radiographic image of the corpora cavernosa and draining veins using contrast medium. Cystography—Radiographic image of the bladder. 17

Chapter 17: Radiology Cystography—Radiographic image of the bladder. Dacryocystography—Radiographic image of the lacrimal drainage system. Discography—Radiographic image of the disc of the spine. Doppler—A type of ultrasound, especially useful for imaging blood flow. The Doppler can create images either in shades of gray or, when processed by a computer, in color. Dual-Energy X-ray Absorptiometry (DEXA/DXA)—Test performed to determine bone density. Ductogram—Imaging of the ducts in the breast. Duodenography—Radiographic examination of the duodenum and pancreas. Echocardiography—Imaging using sound waves to create a moving picture of the heart. Echoencephalography—Ultrasound image of the brain. Epidurography—Imaging of the epidural space in the spine. Fluoroscopy—A continuous X-ray image, used to view the movement of a body part, or of an instrument or dye moving through the body. Hyperthermia—A type of cancer treatment in which tissue is exposed to high temperatures (up to 113°F). Hysterosalpingography—Fluoroscopic imaging (with contrast) of the uterus and fallopian tubes. Intraluminal—Within the lumen. Laryngography—Radiographic image of the larynx. Lymphangiography—Diagnostic imaging to view lymphatic circulation and lymph nodes; utilizes X-ray technology and the injection of a contrast agent. Magnetic Resonance—Magnetic fields align the protons within the body to produce image slices, which are combined to produce 3-D images, may be viewed from different angles; performed either with or without contrast. Myelography—Radiographic image of the spinal cord. Nephrotomography—CT image of the kidneys. Orthopantogram—Panoramic, radiographic image of the entire dentition, alveolar bone, and other adjacent structures on a single film; taken extra-orally. Pachymetry—Measurement of corneal thickness. Pancreatography—Radiographic image of the pancreatic ducts following injection of radiopaque material. Pelvimetry—Measurement of the dimensions and capacity of the pelvis. Positron Emission Computed Tomography (PET)—Nuclear imaging assessing the level of metabolic activity and perfusion in various organ systems of the body. Portography—X-ray visualization of the portal circulation, using radiopaque material. Pyelography—Radiographic imaging of the renal pelvis of a kidney following injection of a radiopaque substance through the ureter or into a vein. Shuntogram—Placement of a radioactive isotope in the shunt reservoir in the head to measure the speed with which it moves to the abdomen. Shuntogram is the term used for angiography of an A/V fistula for renal dialysis. Sialography—Radiographic image of the salivary ducts and glands. Single Photon Emission Computed Tomography (SPECT)—Nuclear imaging using radioactive tracers to show how blood flows to organs and tissues. < | gy h ysterography—Ultrasound imaging of the uterus. Splenoportography—Radiography of the splenic and portal veins, which includes injection of a radiopaque medium. Teletherapy—Any treatment where the source of the therapeutic agent (for example, radiation) is at a distance from the body; delivery of radiation to a tumor from an external beam source as compared to implantation of radioactive material or systemic administration of radionuclide Transcatheter—Performed via the lumen of a catheter. Ultrasound—High frequency sound waves are used to produce two-dimensional images in examining structures inside the body or for detecting abnormalities. Urethrocystography—Radiography of the urethra and bladder using a radiopaque substance. Urography—Imaging of the kidneys, ureters, or bladder. Vasography—Radiographic image of the vas deferens and ejaculatory duct following dye injection. Velocity Flow Mapping—A noninvasive method to image blood flow through the heart by displaying flow data on the two-dimensional echocardiographic image. Venography—A radiographic image of the veins following injection of contrast dye. Xeroradiography—Creation of radiographs by photoelectric process, using metal plates coated with a semiconductor (for example, selenium). 18

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