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.

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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