Step by Step Chapter 24 - Radiology
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Chapter 24: Radiology
Chapter Introduction and Learning Objectives
Chapter Introduction
1.
Contains the codes for reporting a variety of radiology services
a.
The terminology is also specialized
2.
Some of the CPT code descriptions for physician services include physician extender services
a.
Physician extenders:
i.
Nurse practitioners
ii.
Physician assistants
iii.
Nurse Anesthetics
iv.
Etc.
b.
They provide medical services typically performed by a physician
c.
“Physician” may include:
i.
“And other qualified health care professionals” depending on the code
d.
Refer to the official CPT code descriptions and guidelines to determine codes that are appropriate to report services provided by non-physician practitioners
Chapter Learning Objectives
Voices of Experience
Using the Chapter Outline
Lesson 24-1: Learning About the Radiology Section
Lesson Introduction
1.
Radiology:
a.
A branch of medicine that uses radiant energy to diagnose and treat patients
2.
The use of radiology is quite common in today’s world
Lesson 24-1 Learning Objectives
Format and Terminology of the Radiology Section
1.
Radiology
:
a.
A branch of medicine that uses radiant energy to diagnose and treat patients
2.
Radiologists
:
a.
Physicians who specialize in radiology
Terms
1.
Fluoroscopy
:
a.
Views the inside of the body and projects it onto a television screen
b.
Provides a live image whereby the physician can view the function and structure of an organ
c.
Example:
i.
71047, 76000
1.
Chest x-ray with fluoroscopy
2.
SlideShow 24-1:
a.
Shows the use of fluoroscopy in a coronary artery catheterization
b.
Patient with acute myocardial infarction with a thrombus
c.
A guiding catheter is then placed in the ostium of the left coronary artery
i.
An shows proximal total occlusion of the left anterior descending with only slight dye staining of the distal vessel
ii.
The ramus intermedius and circumflex coronaries are free of significant disease
d.
Passage of an angioplasty guidewire into the distal left anterior descending suggests a large filling defect at the site of occlusion, consistent with a large thrombus burden
e.
Initial balloon dilatation restores antegrade flow, and confirms this impression
3.
Magnetic Resonance Imaging (MRI)
:
a.
Another procedure used in radiology
b.
Uses magnetic energy to view the soft tissue structures of the body
c.
Codes such as 72148 (MRI, spinal cord) describe:
i.
Procedures that use magnetic resonance imaging
4.
Tomography
:
a.
Also called Computed Tomography
b.
Used to view a single plane of the body
c.
Example:
i.
Code 70450 documents:
1.
The use of tomography to view the head or
brain on a single plane
d.
There is much greater detail obtained with tomography than
with conventional radiography 5.
Biometry
:
a.
The application of statistics to biologic data
b.
The use of biometry:
i.
Aids the radiologist in the diagnosis of patient conditions
c.
Example:
i.
The use of ultrasound echography in the diagnosis of conditions of the eye
1.
Described in code 76516
Planes of the Body
1.
Planes of the body
a.
Radiologists use these planes when
describing the services provided to patients
b.
CPT codes also use these planes in the code
description
2.
Position:
a.
The way in which the patient is placed
3.
Projection:
a.
The path the x-ray beam travels
4.
In this illustration (fig 24-1, 24-3 in textbook):
a.
The patient is in the supine position (dorsal
decubitus)
b.
The x-ray beam passes from front to back
i.
(anteroposterior)
Medical Terminology Review
1.
Medial
a.
Toward the midline of the body
2.
Superior
a.
Toward the head or the upper part of the body
b.
Also known as cephalad or cephalic
3.
Anterior (ventral)
a.
In front of
4.
Lateral
a.
Away from the midline of the body (to the side)
5.
Posterior (dorsal)
a.
In back of
6.
Inferior
a.
Away from the head or the lower part of the body
b.
Also known as caudad or caudal
Lesson 24-1 Learning Activity
1.
Hysterosalpingography
a.
Uterine cavity and fallopian tubes
2.
Diskography
a.
Intervertebral joint
3.
Urography
a.
Kidneys, renal pelvis, ureters, and bladder
4.
Cholangiography
a.
Bile ducts
5.
Arthography
a.
Joint
6.
Venography
a.
Veins and tributaries
7.
Myelography
a.
Subarachnoid space of the spice
8.
Epididymography
a.
Epididymis
9.
Cystography
a.
Urinary bladder
10. Lymphangiography
a.
Lymphatic vessels and nodes
Lesson 24-1 Quiz
1.
Radiographic contrast medium
a.
Barium enema
2.
Procedure for viewing the interior of the body using x-rays and projecting the image onto a television screen
a.
Fluoroscopy
3.
Photoelectric process of radiographs
a.
Xeroradiography
4.
Application of a statistical method to a biologic fact
a.
Biometry
5.
Procedure that uses nonionizing radiation to view the body in a cross-sectional view
a.
Magnetic resonance imaging (MRI)
6.
Procedure that allows viewing of a single plane of the body by blurring out all but that particular level
a.
Tomography
Lesson 24-2: Describing Radiology Services
Lesson Introduction
Lesson 24-2 Learning Objectives
Component Coding
1.
Component coding
:
a.
A coding practice most commonly used in the Radiology Section
b.
A code from the Radiology Section as well as a code from one of the other sections must
be used to fully describe the procedure
2.
There are three component terms used to describe radiology services:
a.
Professional component
i.
Sometimes called the physician portion of the service
ii.
Includes the supervision of the technician and the interpretation of the results
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1.
Including the preparation of a written report
b.
Technical component
i.
The technologist’s service
ii.
The equipment, film, and supplies necessary to perform the service
c.
Global procedure
i.
A procedure in which both the professional and technical portions of the radiology service are provided
3.
Radiology codes are global codes
a.
If only the professional component of the services was provided:
i.
Add modifier -26 to the code
b.
If only the technical component was provided:
i.
Add HCPCS modifier -TC (Technical Component) to the code
ii.
Modifier -TC is used with both CPT and HCPCS codes
c.
If both the professional and technical components were provided:
i.
No modifier is added to the CPT code
4.
Component Coding Example:
a.
Professional component:
i.
71048-26
ii.
Supervision and final report
b.
Technical component:
i.
71048-TC
ii.
Technician, supplies and equipment
c.
Global procedure:
i.
71048
ii.
Supervision with final report, technical, supplies and equipment
Global Procedures Reimbursement
1.
Third-party payers usually reimburse radiology services as follows:
a.
40% for professional component
b.
60% for technical component
c.
100% for global procedure
2.
Self-Comprehension Questions
Match the usual reimbursement for radiology services with the correct percentage:
1.
Global procedure
a.
100%
2.
Professional component
a.
40%
3.
Technical component
a.
60%
Contrast
1.
Contrast material
:
a.
Is radiopaque:
i.
Radiopaque areas appear light or white on the x-ray film because:
1.
X-rays cannot pass through the contrast material
b.
Placed into the body to improve the view
2.
“With contrast”
a.
Material injected into a vein or artery
b.
Oral or rectal contrast do not qualify for “with contrast”
c.
The statement “with contrast” implies that the injection is part of the code and is not to be reported separately
3.
Guidelines within parentheses will instruct the coder when to refer to the surgical section of the CPT manual
a.
To code an additional procedure for the injection when describing the complete procedure
4.
Example:
a.
An interventional radiologist that owns the radiology equipment and provides the total procedure for a cystography with contrast:
i.
Report 74430
1.
For the x-ray portion of the services
ii.
Report 51600
1.
For the injection procedure
iii.
PLUS a code for the supply of the contrast material
1.
Ex: 99070
Lesson 24-2 Learning Activity
1.
Using the Radiology Guidelines, locate the heading Administration of Contrast Material(s) to complete the following: oral and/or rectal contrast administration alone does not qualify as _______.
a.
A study “with contrast”
2.
Lesson 24-2 Quiz
1.
The injection procedure is bundled into the x-ray procedures that state _____ unless the guidelines state that a surgical code should also be listed to report the injection procedure.
a.
With contrast
2.
Lesson 24-3: Overview of Radiology Subsections
Lesson Introduction
Lesson 24-3 Learning Objectives
Subsections of the Radiology Section
1.
The subsections of the Radiology Section are:
a.
Diagnostic Radiology
b.
Diagnostic Ultrasound
c.
Radiologic Guidance
d.
Breast Mammography
e.
Bone/Joint Studies
f.
Radiation Oncology
g.
Nuclear Medicine
2.
Diagnostic Radiology Subsection
1.
Diagnostic Radiology
:
a.
One of the subsections of the radiology section
2.
Most standard radiographic procedures are within this subsection
a.
Codes are often divided based on whether or not contrast material was used
b.
Codes are further based on the number of views (pictures) taken
3.
Diagnostic Radiology is used to:
a.
Diagnose a disease
b.
To monitor a disease process
i.
Progression or remission
c.
Therapeutic procedures
4.
Diagnostic procedures include the following:
a.
X-ray
b.
Computerized axial tomography
i.
CAT or CT scan
c.
Magnetic Resonance Imaging
i.
MRI
d.
Angiography
5.
Modifier -52, Reduced Service
a.
Use if fewer than the total of number of views specified in the code were provided
Coding Practice
1.
X-ray, elbow with four views, complete
a.
CPT Code: 73080
2.
Radiologist performs a fluoroscopic bronchoscopy lasting two hours. Code only the radiologist’s service
a.
CPT Code: 76000
Diagnostic Ultrasound Subsection
1.
Diagnostic Ultrasound
:
a.
Uses high-frequency sound waves to image anatomic structures
b.
There are 9 subheadings in Diagnostic Ultrasound that are based primarily on anatomy
2.
Ultrasound Modes and Scans:
a.
A-mode: Amplitude
i.
Technique used to map structure outlines
ii.
Displays a one-dimensional image
b.
M-mode: Motion
i.
Technique used to display the movement of the structure
ii.
Displays a one-dimensional image
c.
B-scan: Brightness
i.
Technique used to display the movement of tissues and organs
1.
AKA gray-scale ultrasound
ii.
Displays a two-dimensional image
d.
Real time scan
i.
Technique used to display both structure and motion of organ and tissue
ii.
Displays a two-dimensional image
Location of Diagnostic Ultrasound Codes
1.
Location of the Diagnostic Ultrasound Codes
:
a.
The ultrasound codes are often divided based on extent
b.
Example:
i.
Was the scan:
1.
Complete scan
a.
Entire body scan
2.
Limited scan
a.
Part of the body
b.
Ex: one organ
3.
Follow-up or repeat
a.
Limited study of part of the body, previously scanned
2.
There are 3 locations for ultrasound service codes:
a.
76506-76886
:
i.
Radiology codes for diagnostic ultrasound services
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ii.
Ultrasonic guidance codes are in the range 76932-76965
b.
93880-93998
:
i.
Medicine codes for vascular studies
c.
93303-93355
:
i.
Medicine codes for echocardiography
Three Interesting Subsections
1.
Radiologic Guidance Subsection (77001-77022)
a.
Fluoroscopic
b.
Computed tomography
c.
Magnetic Resonance Imaging
d.
Other
2.
Breast, Mammography Subsection (77046-77067)
a.
Computer-aided detection and screening
3.
Bone/Joint Studies Subsection (77071-77086)
a.
Bone density
b.
Bone mineral density
c.
Joint survey
Radiation Oncology Subsections
1.
Radiation Oncology
a.
The therapeutic use of radiation that involves both professional and technical services
2.
The subsection is divided into subsections based on the treatment
a.
The initial consultation, prior to the decision to treat is reported with:
i.
E/M consultation code
ii.
Initial inpatient:
1.
Report codes 99252-99255
iii.
Initial Outpatient:
1.
Report codes 99242-99245
3.
Clinical Treatment Planning:
a.
The professional component
b.
Includes:
i.
Interpretation of special testing
ii.
Tumor localization
iii.
Determination of treatment volume of radiation
iv.
Choice of treatment method
v.
Determination of number of treatment ports
1.
Locations in which the radiation is placed
vi.
Selection of treatment devices
vii.
Other necessary procedures used for the treatment
c.
Consists of planning a simulation
i.
Planning:
1.
Simple
:
a.
One treatment area, one port, or one set of parallel ports
2.
Intermediate
:
a.
Three or more ports, two separate treatment areas, and multiple blocking
3.
Complex
:
a.
Highly complex blocking, custom shielding blocks, tangential ports, special wedges, three or more treatment areas, and special beams
ii.
Simulation:
1.
Determining the placement of treatment area/ports for radiation treatment
2.
Simulation does not include the administration of the radiation
3.
Simple
:
a.
Single treatment area with a single port or set of parallel ports, simple or no blocking
4.
Intermediate
:
a.
Three or more converging ports, two separate treatment areas, multiple blocking
5.
Complex
:
a.
Tangential ports, three or more treatment areas, complex blocking, custom shielding blocks, any use of contrast material
Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Service Subheading
1.
Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Service subheading
:
a.
An important subheading within the Radiation Oncology subsection
2.
The codes in this subheading represent the decision making services of the physician regarding:
a.
The type of treatment
b.
Dose calculation
c.
Placement (dosimetry)
d.
Development of the treatment device(s)
3.
Radiation Treatment Delivery category codes are used to report the actual delivery of the radiation
a.
The information you need to correctly code the delivery of the radiation treatment is:
i.
Amount of radiation delivered
ii.
Number of areas treated
1.
Single, two, three, or more
iii.
Number of ports involved
1.
Single, three or more, or tangential
iv.
Number of blocks used
1.
None, multiple, custom
4.
Intensity-modulated radiation treatment
(IMRT)
a.
Reported with 77385-77387
b.
An advanced type of radiation therapy to treat cancer and non-cancerous tumors
c.
The treatment of delivery manipulates beams that conform to the shape of the tumor
d.
IMRT delivery reduces the exposure to healthy tissue and also limits the side effects of treatment
Reporting Radiation Treatment Management
1.
Radiation Treatment Management codes
:
a.
Reflect the reporting of the professional component
2.
The professional (physician) portion of the service includes:
a.
Review of the port films
b.
Review of:
i.
Dosimetry
ii.
Dose delivery
iii.
Treatment parameters
c.
Treatment setup
d.
Patient examination for medical evaluation and management
Clinical Brachytherapy
1.
Clinical Brachytherapy
:
a.
The placement of the radioactive material into or around the site of the tumor
b.
The placement can be intracavitary or interstitial
i.
Intracavity:
1.
Within the body
ii.
Interstitial
1.
Within the tissue
2.
The source is a container of a radioactive element that can be inserted directly into the body where it delivers the radiation dose over time
a.
Examples:
i.
Seeds
ii.
Ribbons
1.
Seeds embedded in tape
2.
Tape is cut to the desired length to control the amount of radiation
3.
Ribbon is temporarily inserted into the tissue
iii.
Capsules
3.
The codes in the Clinical Brachytherapy subsection are divided based on the number of sources or ribbons applied:
a.
Simple:
i.
1 to 4
b.
Intermediate:
i.
5 to 10
c.
Complex:
i.
11 or more
Nuclear Medicine Subsection
1.
Nuclear Medicine
:
a.
Involves the placement of radioactive material into the body and the subsequent measurement of the emissions from that material
b.
This technique is used for:
i.
Diagnosis
ii.
Treatment
2.
The codes are divided primarily based on organ system:
a.
Endocrine system
b.
Gastrointestinal system
c.
Cardiovascular system
d.
Therapeutic:
i.
Contains the radiopharmaceutical therapies
ii.
Divided based on:
1.
Type of treatment
a.
Intracavity
b.
Interstitial
2.
Reason for treatment
a.
Leukemia
b.
Hyperthyroidism
3.
The codes DO NOT include the material injected
a.
Material injected is radionuclides
b.
Report the radionuclides with therapeutic codes such as:
i.
79101
1.
Intravenous
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ii.
79200
1.
Intracavity
iii.
79300
1.
Interstitial
iv.
OR Level II HCPCS code
Changing Radiology Section
1.
Each year there are numerous changes within the Radiology Section to reflect the many advances in the use of radiation in the diagnosis and treatment services
2.
Keep this in mind so that your knowledge of coding within this section is current
Lesson 24-3 Learning Activity
1.
Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation
a.
33016
2.
Three-view x-ray of cervical spine, anteroposterior and lateral
a.
72040
3.
X-ray of sacroiliac joints, two views
a.
72200
4.
Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation
a.
76948
5.
Myelography of posterior fossa, radiologic supervision and interpretation
a.
70010
6.
Dacryocystography of nasolacrimal duct, radiologic supervision and interpretation
a.
70170
7.
MRI Report:
Examination of
: MRI cervical spine.
Clinical Symptoms
: Left shoulder and neck pain.
Magnetic Resonance Examination of the Cervical Spine
: This was performed utilizing a combination of T1, gradient echo and fast spin echo T2-weighted sequences. At C5-6 and C6-7, there is prominent bulging of the intervertebral discs and effacement of the anterior and posterior subarachnoid spaces. This is more prominent at C5-6. The spinal cord retains normal intensity. I believe the patient might have pre-existing mild congenital spinal stenosis. No plain films are available for review. Intervertebral foramina at C5-6 and C6-7 appear narrowed in the axial images, particularly on the right. This could be due to plane of section but might also indicate osseous encroachment.
I do not appreciate significant abnormality at other cervical levels.
Impression
: Moderate degenerative changes of the intervertebral disc spaces at C5-6 and C6-7, with prominent bulging of the intervertebral discs at both levels, somewhat more to the right than the left. Spinal stenosis is created, with at least partial effacement of anterior and posterior
subarachnoid spaces. This is more prominent at C5-6 where there is almost no subarachnoid space available for the spinal cord. The cord retains normal contour and intensity. I would suggest review of any lateral cervical plain films to examine for the possibility of congenital osseous stenosis. I would also examine any available oblique plain films for osseous encroachment on the intervertebral foramina at C5-6 and C6-7.
a.
72141
Lesson 24-3 Quiz
1.
X-ray of abdomen, two views
a.
74019
2.
Endoscopic catheterization of the biliary and pancreatic ductal systems, radiologic supervision and interpretation
a.
74330
3.
Orbital venography, radiologic supervision and interpretation
a.
75880
4.
CT guidance for placement of radiation therapy field
a.
77014
5.
Bone marrow imaging study of multiple areas
a.
78103
6.
Pulmonary ventilation imaging, gaseous, with perfusion imaging
a.
78582
b.
7.
MRI Report:
Examination of
: MRI of lumbar spine.
Magnetic Resonance Examination of the Lumbar Spine
: This was performed utilizing T1, gradient echo and fast spin echo sagittal sequences. These were supplemented with axial T1 and
fast spin echo sequence from L2 to S1.
L2-3 level
: There is no significant compression on the ventral aspect of the thecal sac. The L2 nerve roots appear to exit the neural foramina normally bilaterally. There is no significant spinal stenosis nor degenerative changes.
L3-4 level
: No significant compression on the ventral aspect of the thecal sac. The L3 nerve roots
appear to exit the neural foramina normally bilaterally. There is no significant spinal stenosis. There are mild degenerative changes, including facet joint overgrowth.
L4-5 level
: There is evidence of disc protrusion causing compression on the ventral aspect of the thecal sac. It is difficult to determine whether this represents a prominent disc bulge versus a small disc herniation. Clinical correlation is recommended. The L4 nerve roots appear to exit the neural foramina normally bilaterally. No significant spinal stenosis. There are mild to moderate degenerative changes.
L5-S1 level
: There is evidence of disc protrusion causing compression on the ventral aspect of the thecal sac centrally and paracentrally to the right. It is difficult to determine whether this represents a prominent disc bulge versus a small disc herniation, although on the axial images this is felt to represent a small disc herniation. Clinical correlation is recommended. The L5 nerve
roots appear to exit the neural foramina normally bilaterally. There is no significant spinal stenosis. There are mild to moderate degenerative changes.
Impression
: There is evidence of disc protrusion causing compression on the ventral aspect of the thecal sac at the L4-5 level. It is difficult to determine whether this represents a prominent disc bulge versus a small disc herniation. Clinical correlation is recommended.
a.
72148
8.
Radiology Report:
Examination of:
Left shoulder.
Clinical Symptoms
: Questionable dislocation.
Two Views Left Shoulder
: First is dated 22:16 and second is dated 23:23 as far as the time. Comparison date 09/12/XX. On the film obtained at 22:16, there is abnormal alignment of the glenohumeral joint. The humeral head is inferior and medial in relation to the glenoid, consistent with anterior dislocation. A single film was then obtained at 23:23 and the previous dislocation appears to have been reduced. Alignment is grossly normal. However, only one view was obtained. There is again Hill-Sachs deformity along the superior aspect the humeral head; this was previously noted. Examination was limited to those two views.
a.
73030
Chapter Review
Chapter 24 Review
Chapter Review Exercises
Take A Break
Taking the Chapter Exam
Chapter 24 Self-Practice Questions Part 1
1.
Tomography is used to view the _____ of the body.
a.
Soft tissues
2.
The application of statistics to biological data is:
a.
Biometry
3.
This term means the way in which the patient is placed for an x-ray:
a.
Position
4.
What are the radioisotopes that attach themselves to the red blood cells?
a.
Tracer
5.
This is a radiographic procedure of the veins and tributaries:
a.
Venography
6.
If the physician provided only the professional component of a radiography service, you would append this modifier to the code for that service:
a.
-26
7.
What is the term that describes both the professional and technical component of a radiographic service?
a.
Global
8.
This is the only contrast that qualifies as “with contrast”:
a.
Injected
9.
Real-time scans display:
a.
Structure and motion
10.
This type of simulation would include tangential parts:
a.
Complex
Chapter 24 Self-Practice Questions Part 2
1.
Ultrasonic guidance for localization of nodule in the right breast. CPT Code:
a.
76942
2.
Consultation and written report on an x-ray examination made elsewhere. CPT Code:
a.
76140
3.
Sixty-two minutes of physician time performing a transbronchial biopsy that utilized fluoroscopy. Code the fluoroscopy guidance only. CPT Code:
a.
76000
4.
Two view x-ray of thoracic spine. CPT code:
a.
72070
5.
Complete ultrasound of abdomen using real time with image documentation. CPT Code:
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a.
76700
6.
Radiology Report:
EXAMINATION OF: Renal ultrasound.
CLINICAL SYMPTOMS: Renal failure.
RENAL ULTRASOUND: Clinical information states renal failure.
Right kidney is 9.5 x 5.6 x 4.9 cm. The size and parenchymal thickness is within normal limits. No cystic or solid mass right kidney seen. No dilatation of calyces to suggest obstruction of collecting system.
Left kidney is 10.9 x 5.4 x 5.5 cm. It shows parapelvic cyst midportion of kidney. The cystic lesion measures 7.1 x 6.3 x 6.2 cm. Usually cysts are not of significance. No solid lesion is seen. No dilatation of calyces is noted.
In the urinary bladder region, no structure resembling bladder is seen. Presumably it is nondistended.
IMPRESSION
1. Kidney size and renal parenchyma thickness normal bilaterally.
2. Cystic lesion, left kidney, likely not of clinical significance.
3. No cystic lesion, right kidney.
4. Neither kidney shows solid lesion nor neither kidney shows evidence of dilated calyces or renal pelvis to suggest obstruction.
5. Urinary bladder not seen and not therefore evaluated.
Report only the physician service, not the technical component of the service. The answer requires a modifier. CPT Code and modifier:
a.
76770-26