CPC Chapter 17

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

CASE 2 Location: Regional Hospital(The hospital will report the technical component. Only the professional component should be reported.)MRI OF THE LUMBAR SPINEHistory: Low back pain.(Reason for the MRI, also known as Lumbago.)Technique: On a 1.5 Tesla magnet multiple sagittal and axial(Sagittal and axial images were taken.)images were performed through the lumbar spine(Location—lumbar spine.) using variable pulse sequences.Findings: There is normal lumbar alignment. The conus is in normal position at the thoracolumbar junction. No suspect bone marrow lesions are present. There is mild anterior wedging of the L3 vertebral body. I am uncertain whether this is an acute or chronic finding.At the T12-L1 level, there is a small posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis.At the L1-2 level, there is no disc bulge or protrusion. There is no central canal or neural foraminal stenosis.At the L2-3 level, there is moderate loss of disc height. There is 106s of T2 signal. There is a focal area of increased T1 signal involving the L2-3 disc. This could be related to disc calcification or possibly blood product. There is a small posterior disc bulge.

72148-26, M48.56XA, M51.26, M51.36

Doopler Study:

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.

HCPCS Level II:

A HCPCS Level II 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 II code. Example: G0219 PET imaging whole body; melanoma for noncovered indications

PET:

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.

Example:

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.

Acronyms:

AP Anteroposterior CT Computed tomography CTA Computed tomography angiography KUB Kidneys, ureter, bladder LL Left lateral MRA Magnetic resonance angiography MRI Magnetic resonance imaging PA Posteroanterior RL Right lateral S & I Supervision and interpretation TMJ Temporomandibular joint

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.

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. 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 lar

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.

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-Z01.818 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.

Posterior (Dorsal)

Anterior (Ventral)

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.

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.

DXA is also called ___.

Bone Density Studies

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.

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.

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.

Radiation Treatment Delivery:

Code 77387 reports guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking when performed.

Neutron Beam Treatment Delivery:

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).

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 Radiology (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.

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.

DSA:

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.

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.

During an encounter, either a diagnostic ultrasound code or an ultrasound guidance code may be reported, but not both.

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).

Anatomic Position:

Erect, facing forward, arms rotated outward with the palms forward, hands open with thumbs pointed out. The feet are together or slightly apart.

ICD 10:

Examination/Radiological

*For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit 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 Z01.89 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.*

Example: 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 R00-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.

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.

ICD 10:

Findings / Abnormal / Inconclusive Examination / Preoperative

Fluoroscopy:

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.

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.

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.

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 113oF). 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.

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 MRI 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.

Supervision and Interpretation:

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&I codes can be reported with modifier 26 for the Professional Component or modifier TC for the Technical Component.

CT:

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. MRI may be used for needle placement and parenchymal tissue ablation as well.

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.

MRA:

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.

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. 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.

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.

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.

Other Procedures:

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.

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 II 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.

Incidental Finding:

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.

Pelvic Ultrasounds:

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.

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).

Proton Beam Treatment Delivery:

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.

Radiation Onocology:

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. 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. 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 CPT® guidelines.

Therapeutic:

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.

SPECT:

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, as in 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 to 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.

Oblique Position:

Slanted position where the patient is lying at an angle neither prone nor supine. In radiology, you may see Right anterior oblique (RAO), Left anterior oblique (LAO), Right posterior oblique (RPO), 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.

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 corneal pachymetry is a test to determine corneal thickness. Topical anesthesia is required for corneal pachymetry because the probe must touch the corneal 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.

*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 an 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.

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.

Stereotactic Radiation Treatment Delivery:

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 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.

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.

Portable, Hand-held 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.

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 II code can be reported in addition to the scan. When the services are performed in a facility, the facility reports the radiopharmaceuticals.

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. 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.

Gadolinium is a contrast used with MRIs. Iodine (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 II 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.

Morphology Ultrasound is sometimes called an ___.

anomaly scan (In ICD 10 look for Encounter / Antenatal Screening / Malformations - don't need a code for weeks of pregnancy)

Frontal (Coronal) Plane:

divides the body into anterior and posterior parts

Midsagitial Plane:

divides the body into equal left and right halves

Sagitial Plane:

divides the body into left and right portions

Transverse (Axial/Horizontal) Plane:

divides the body into superior and inferior halves

Extension:

joint is imaged while extending

Flexion:

joint is imaged while flexed

Decubitus:

laying down

Stress Veiws:

taken to stress stability in a joint

Caudal:

towards feet