RADIOLOGY CODING BASICS

1. RADIOLOGY CODING BASICS Presented by WENDIE POND, CPC (former RCC) Healthcare Billing and Coding Consultant

2. What is an RCC?

3. What is an RCC? REAL COOL CODER?

4. What is an RCC? REAL COOL CODER? REALLY CRAZY CHICK?

5. What is an RCC? REAL COOL CODER? REALLY CRAZY CHICK? RADIOLOGY CERTIFIED CODER!!!!

6. RBMA RBMA-Radiology Business Management Association • Founded in 1968, is the only radiology-specific business organization in existence today. It’s purpose is to provide Radiology managers with information, resources, education and networking to run a successful radiology business. • The RBMA recognized the importance of radiology coding in the business of radiology and approved the development and funding of the first nationally recognized radiology specific coding exam. • In the spring of 2000 the Radiology Coding Certification Board (RCCB) was formalized.

7. RCCB RCCB-Radiology Coding Certification Board • A non-profit organization established in May 2000, committed to promoting the highest standards of radiology coding through the credentialing of radiology coders. • The RCCB has certified over 1682 coders to date. Currently there are only 35 RCC’s in Washington State.

8. What Makes Radiology Coding so Different? • Its subjective • After all its a PHOTO • Photos are hard to diagnose…Right?

9. What Makes Radiology Coding so Different? • Its subjective

10. What Makes Radiology Coding so Different? • Its subjective

11. What Makes Radiology Coding so Different? • Its subjective

12. What Makes Radiology Coding so Different? • Its subjective

13. PHOTOS ARE SUBJECTIVE • “Appears to be…” • “Consistent with…” • “Similar to…” • “Suggestive of…” NOT CODEABLE LANGUAGE…

14. Some things are Obvious!

15. RULE OUTS… • Images are often ordered to “Rule Out” a condition. “ Patient complains of RUQ Abdominal pain. Rule out cholelithiasis” “Shortness of Breath for 2 days, Rule out Pulmonary Embolism” “Lower leg pain and swelling, Rule out DVT”

16. WHATS CODEABLE?? • ABDOMINAL ULTRASOUND IS ORDERED

17. WHATS CODEABLE?? • ABDOMINAL ULTRASOUND IS ORDERED • Reason for Visit: • Rule-out Hernia

18. WHATS CODEABLE?? • ABDOMINAL ULTRASOUND IS ORDERED • Reason for Visit: • Rule-out Hernia • Findings: • No Hernia Found

19. WHATS CODEABLE?? • ABDOMINAL ULTRASOUND IS ORDERED • Reason for Visit: • Rule-out Hernia • Findings: • No Hernia Found NOTHING…THE CODER NEEDS FINDINGS or “SYMPTOMS”. IN OTHER WORDS…WHAT IS IT THAT MAKES THE REFERRING PHYSICIAN “THINK” THERE IS A HERNIA????

20. MAMMOGRAPHY REPORT • Patient presents with palpable lump found during routine breast exam. • Mammography findings state the following “2cm mass seen at 2 o’clock in the left breast is consistent with DCIS (ductal carcinoma in-situ). Ultrasound guided breast biopsy has been scheduled.” WHAT WOULD THE CODER USE FOR ICD-9 CODE?

21. MAMMOGRAPHY REPORT • Patient presents with palpable lump found during routine breast exam. • 611.72-Mass or lump in Breast • Mammography findings state the following “2cm mass see at 2 o’clock left breast consistent with DCIS (ductal carcinoma in-situ). Ultrasound guided breast biopsy recommended” CANT CODE THE “CONSISTENT WITH…”

22. RADIOLOGY PROCEDURES • CPT 70000 series** • MULTIPLE MODALITIES • MRI-Magnetic Resonance Imaging • CT-Computerized Tomography • ULTRASOUND** • Nuclear Medicine • PET- Positron Emission Tomography • Mammography • Fluoroscopy • X-ray • Interventional

23. MRI-Magnetic Resonance Imaging • MR imaging uses a powerful magnetic field, radio frequency pulses and a computer to produce detailed pictures of organs, soft tissues, bone and virtually all other internal body structures. • MRI often uses a para-magnetic contrast material: • Intravenously (no additional cpt code for IV. HCPCS code used for contrast material) • Example of how CPT codes designate this: • 70551-MRI Brain without contrast • 70552- MRI Brain with contrast • A9579 Gadolineum • 70553-MRI Brain without contrast followed by contrast material and further sequences. • A9579 Gadolineum

25. CT – Computed Tomography • CT imaging combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied can then be examined on a computer monitor and provide greater clarity and reveal more details than regular x-ray exams. • CT exams are often done with Contrast Material: • Intravenously • Orally (Not considered a w/ contrast exam per CPT) • Examples: • 70490 – CT Neck Soft Tissue without contrast • 70491 – CT Neck Soft Tissue with contrast material (IV) • 70492 – Ct Neck Soft Tissue without contrast followed by contrast material and further sections. • 74150 - CT Abdomen without contrast material • 74150 - CT Abdomen without contrast material (patient received Oral Contrast) • IMPORTANT TO REMEMBER-FOR CODING PURPOSES “WITH CONTRAST CT REFERS TO INTRAVENOUS, INTRATHECAL OR INTRA-ARTICULAR ONLY”.

26. CT – Computed Tomography • CT Chest (apices through the level of the adrenal glands) • 71250 – without contrast • 71260 - with contrast • 71270 - without contrast followed by contrast and further images (referred to as with/without) • CT Abdomen (dome of the diaphragm to the iliac crest ) • 74150 – without contrast • 74160 – with contrast • 74170 - without contrast followed by contrast and further images • CT Pelvis (Aortic bifurcation to the symphysis pubis) • 72192 – without contrast • 72193 – with contrast • 72194 - without contrast followed by contrast and further images • CT Abd/Pelvis (new last year) • 74176 – without contrast • 74177- with contrast • 74178 - without contrast followed by contrast and further images (any combination of with and/or without exams. ie. Abdomen without and pelvis with and without)

27. CT – Computed Tomography One Scan can sometimes equal multiple CPT’s • “Computed tomography was obtained from the apices to the symphysis pubis following the administration of iodinated contrast and oral contrast.” • 71260 – Chest with Contrast • 74177 – Abd/Pelvis with Contrast • Q9967 – Lo osmolar contrast material • “Following Oral Contrast, Computed tomography was obtained following from the dome of the diaphragm thru the iliac crest without IV contrast. Additional images were then obtained from the dome of the diaphragm thru the symphysis pubis with the administration of iodinated IV contrast.”

28. CT – Computed Tomography One Scan can sometimes equal multiple CPT’s • “Computed tomography was obtained from the apices to the symphysis pubis following the administration of iodinated contrast and oral contrast.” • 71260 – Chest with Contrast • 74177 – Abd/Pelvis with Contrast • Q9967 – Lo osmolar contrast material • “Following Oral Contrast, Computed tomography was obtained following from the dome of the diaphragm thru the iliac crest without IV contrast. Additional images were then obtained from the dome of the diaphragm thru the symphysis pubis with the administration of iodinated IV contrast.” • 74178 – Abdomen Pelvis without following by with contrast • Q9967 – Lo osmolar contrast material

29. CT – Computed TomographyOften called cross sectional imaging

30. ULTRASOUND/ULTRASONOGRAPHY • Ultrasound imaging involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound exams do not use radiation. Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels. • US also had codes outside of the 70000 series • Non Invasive Vascular Diagnostic Studies 93800-93990 These are often called Dopplers or Duplex Scans Most common uses for US are Abdominal imaging, OB and Gynecological imaging and Venous/Arterial blood flow imaging.

31. ULTRASOUND/ULTRASONOGRAPHY

32. US-ABDOMEN • Dictation must mention the following 8 elements to be considered a full (76700) vs a limited (76705) • Upper Abd. Aorta • Inferior Vena Cava • Common Bile Duct • Gall Bladder • Kidneys • Liver • Pancreas • Spleen

33. US- Retroperitoneal (renal) • 76770 complete vs. 76775 limited • Complete exam consists of • Kidneys • Abd Aorta • Common Iliac Artery origins • IVC • UNLESS clinical history suggests Urinary Tract pathology then a complete evaluation of the Kidneys and Urinary Bladder also comprises a complete.

34. Ultrasonic Guidance Includes guidance for: • Pericentesis (cpt 49083) • Thoracentesis (cpt 32555) • Vascular access • Intrauterine fetal transfusion or cordocentesis • Needle placement • Chorionic villus sampling • Amniocentesis • Aspiration of ova

35. Nuclear Medicine • Nuclear medicine is a branch of medical imaging that uses small amounts of radioactive material to diagnose or treat a variety of diseases. • Thyroid function (endocrine) • 78012 Thyroid Uptake • A9516 Iodine-123 • Renal (Gastrointestinal System) • Bone (Musculoskeletal System) • 78306 Bone imaging Whole Body • A9503 TC99M MDP • Heart (Cardiovascular system) • Brain (Nervous System)

36. PET–Positron Emission Tomography • Positron emission tomography is a type of nuclear medicine imaging typically used in the diagnosis and staging of cancer.

37. Mammography • Mammography is a specific type of imaging that uses a low-dose x-ray system to examine breasts. It is used to aid in the early detection and diagnosis of breast diseases in women. • Two recent advances in mammography include digital mammography and computer-aided detection. • CPT Codes: • 77056 – Diagnostic Mammography, bilateral; film • G0204 – Diagnostic Mammography, bilateral; digital • G0206 - Diagnostic Mammography, unilateral; digital • 77051- Diagnostic CAD (computer aided detection) • 77057 – Screening Mammography, film • G0202 – Screening Mammography, digital • 77052 - Screening CAD

38. Fluoroscopy & Xray • Imaging with x-rays involves exposing a part of the body to a small dose of radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. • Fluoroscopy makes it possible to see internal organs in motion using the same technology as x-ray. • CPT Code - watch # of views • 71020 – Chest xray 2 view • 71010 – Chest xray 1 view

39. Interventional • Interventional Radiology is the practice of “Treatment” of a patients condition, not just diagnosing it. • Examples of Interventional: • CT or US guided Biopsies • US guided Paracentesis or Thoracentesis • Uterine Artery Embolizations for Uterine Fibroids • Pain Management Epidurals or Joint Injections All I.R. will have a “surgical” component CPT code.

40. MODIFIERS Radiology exams consist of two components- -TC Technical component (using the machine to take the picture) -26 Professional component (reading of the xray by the radiologist) No modifier used if billing Global (full exam) Exams done bilaterally (arms, legs etc.) - RT Right - LT Left Exams with same CPT code for different sites (MRI- any jt. lower ext) - 59 Distinct Procedural Svc. Other common modifiers used in radiology - 76 Repeat procedure by same physician - 77 Repeat procedure by different physician

41. Examples of Modifier Use • Chest Xray done by Pediatricians office and sent to Radiologist to be interpreted • 71020-TC billed by pediatricians office • 71020-26 billed by radiologist • Chest Xray done in a Radiology Clinic • 71020 billed by radiology clinic • Right and Left Knee MRI’s done at a Radiology Clinic • 73721-LT • 73721-RT • Right Knee and Right Ankle MRI done at Radiology clinic • 73721-RT • 73721-59, RT • Chest Xray upon admit to hospital and again 10 hrs later-same day • 71020 • 71020-76 if read by same radiologist OR 71020-77 if different radiologist

42. Compliance • Radiology DON’TS!

43. Compliance • Radiology DON’TS! • IF ITS NOT IN THE WRITTEN REPORT…IT DIDN’T HAPPEN AND YOU CANT CODE IT!

44. Compliance • Radiology DON’TS! • IF ITS NOT IN THE WRITTEN REPORT…IT DIDN’T HAPPEN AND YOU CANT CODE IT! • IF IT WASN’T ORDERED BY A REFERRING PHYSICIAN, EVEN IF IT WAS DONE, YOU CAN’T BILL FOR IT.

45. Compliance • Radiology DON’TS! • IF ITS NOT IN THE WRITTEN REPORT…IT DIDN’T HAPPEN AND YOU CANT CODE IT! • IF IT WASN’T ORDERED BY A REFERRING PHYSICIAN, EVEN IF IT WAS DONE, YOU CAN’T BILL FOR IT. • CONFIRMED SYMPTOMS OR FINDINGS ONLY!!