AAPC Chapter 17: Radiology

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?

Z01.818 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.

The path of the X-ray beam is known as?

Projection RATIONALE: The projection is the path the X-ray beam takes through the body.

A patient is taken to the inpatient cardiac cath lab and 1% Lidocaine is infused into the skin of the right groin. The artery is punctured with a needle and a guidewire with a catheter is advanced into the abdominal aorta. The guidewire is removed. Contrast medium is injected through the catheter and abdominal aortography is performed. What CPT® code(s) is/are reported for the physician's services?

36200, 75625-26 Rationale: The physician gains access to the aorta through the right groin (femoral artery). The procedure is reported with 36200. In the CPT® Index look for Catheterization/Aorta 36106, 36200. In the CPT® Index look for Aorta/Aortography or see Aortography/Aorta Imaging. Abdominal aortography is performed which is reported with 75625. There is no documentation that both iliofemoral arteries of the lower extremities were also performed, code 75630 is not reported. The services were provided by the physician in the inpatient setting. Append modifier 26 to indicate the professional component.

CASE 10 Location: Regional Hospital TYPE OF PROCEDURE: 1. Abdominal aortic angiogram 2. Mesenteric artery angiogram HISTORY: Mesenteric ischemia. INFORMED CONSENT: The procedure was discussed with the patient and his wife. The risks, including bleeding, infection and vascular injuries such as dissection, perforation, thrombus, and embolus were outlined. Informed consent was obtained. CONTRAST: 123 ml Ultravist 370. DESCRIPTION OF PROCEDURE: The patient's right groin was sterilely prepped and draped. The skin and subcutaneous tissues were anesthetized with 2% lidocaine. The right common femoral artery was then percutaneously accessed and a wire advanced into the abdominal aorta under fluoroscopic visualization. A 5-French vascular sheath was placed into the right groin. An Omni Flush catheter was advanced to the upper abdominal aorta. Digital subtraction angiography of the abdominal aorta was performed. It demonstrates mild tortuosity of the aorta. The caliber is normal. A single renal artery is seen bilaterally without stenosis. The common iliac vessels are patent. The Omni Flush catheter was then exchanged for a Cobra 2 catheter. The superior mesenteric artery was then selectively catheterized. Digital subtraction angiography was performed in multiple obliquities. The origin is patent. No focal stenosis or branch occlusions are identified. Next, the celiac artery was selectively catheterized. Digital subtraction angiography was performed in 2 obliquities. The origin is normal. No focal stenosis or branch occlusions are present. Next, attempts were made to catheter the inferior mesenteric artery with the Cobra 2 catheter. This was unsuccessful. Selective catheterization of the inferior mesenteric artery was achieved with a Simmons 2 catheter. Digital subtraction angiography was then performed in 2 obliquities. The origin is patent. No stenosis or branch occlusions are present. The Simmons 2 catheter was removed as was the right groin sheath over a wire. Hemostasis in the right groin was then achieved using an Angio-Seal closure device. IMPRESSION: Normal abdominal aortic angiogram and mesenteric angiogram of selective catheterization of the celiac, superior mesenteric and inferior mesenteric arteries. What are the CPT® and ICD-10-CM codes reported for this service?

36245, 36245-59, 36245-59, 75726-26, 75726-26-59, 75726-26-59; K55.9

A 82 year-old female with a right leg medial malleolar non-healing ulcer elected to proceed with peripheral angiography. Using a RIM catheter, from a left femoral artery access, the contralateral right iliac artery was accessed and the catheter was gradually advanced to the right common femoral artery. The right lower extremity angiography was performed with both C02 injection and subsequently localized pictures of femoral distal bypass grafts were performed using contrast injections. This revealed the right superficial femoral artery is 100% occluded at its origin. Decision for angioplasty was made and intervention was performed through this area with a 7 mm x 20 mm balloon inflated up to 7 atmospheres. The gradual inflation resulted in enlarging the artery to a more normal flow of blood. What CPT® codes is/are reported?

37224, 75710-26-59 Rationale: The second order selective catheterization (36246) for the diagnostic angiography will not be reported as an additional code because the catheterization was performed through the same access site as the interventional angioplasty, code 37224. The diagnostic angiography is reported with 75710-26-59. Because the decision to perform the angioplasty was made after reading the films for the diagnostic angiography, modifier 59 is appended to show that it is not bundled with code 37224.This information is found in the Vascular Procedures Guidelines of the Radiology Section in the CPT® codebook. In the CPT® Index look for Angioplasty/Femoral Artery/Intraoperative which directs you to 37224. Look for Angiography/Leg Artery directing you to 73706, 75635, 75710-75716.

The patient has malignant ascites due to ovarian cancer. She is coming back to the operating room for a planned ultrasound guided abdominal paracentesis. This is the second time she has needed fluid removed from her abdominal cavity. The global days for the initial abdominal paracentesis are zero. What CPT® and ICD-10-CM codes are reported?

49083, C56.9, R18.0 Rationale: The patient is coming in for a subsequent (second or staged) abdominal paracentesis. In the CPT® Index look for Paracentesis/Abdomen directing you to 49082-49083. Code 49083 includes imaging guidance so the radiology codes are not separately reported. 49083 does not have a post-operative period because it has 000 for the global days indicator. Modifier 58 is not required. Look in the ICD-10-CM Alphabetic Index for Cancer and you are directed to see also Neoplasm, by site, malignant. Go to the ICD-10-CM Table of Neoplasms and look for Neoplasm, neoplastic/ovary and select from the Malignant Primary (column) guiding you to code C56.-. In the Tabular List a 4th character is reported to complete the code. Malignant ascites is found by looking for Ascites/malignant which directs you to code R18.0. In the Tabular List there is a code first note under code R18.0 indicated to "Code first malignancy, such as: malignant neoplasm of ovary (C56.-); secondary malignant neoplasm of retroperitoneum and peritoneum (C78.6)." This means the malignant ascites is reported as a secondary code and the ovarian cancer is reported as the primary diagnosis code.

Tomographic axial images (CT or CAT scan) through the abdomen were obtained without administration of intravenous contrast. This showed a 3 cm diameter mass in the upper pole of the right kidney abutting the liver. Cryoablation of the lesion was performed utilizing two freezing cycles with good cosmetic results. What CPT® codes are reported?

50250, 77013-26 Rationale: A kidney (renal) mass, not tumor, is being destroyed (ablation) by freezing (cryoablation) the lesion to remove it. This procedure was performed under CT (computed tomography) guidance to ablate parenchymal (vital organ-example: kidney) tissue. Look in the CPT® Index for Ablation/Cryosurgical/Renal Mass directing you to 50250. Cryosurgery/Lesion/Kidney also leads to 50250. 50250 includes ultrasound guidance if performed. The CT guidance was performed to locate the mass and not to accomplish the ablation. CT guidance is found in the CPT® Index by looking for Ablation/CT Scan Guidance directing you to code 77013. Modifier 26 denotes the professional service.

CASE 7 Location: Regional Hospital Fluoro Hysterosalpingogram EXAMINATION: HYSTEROSALPINGOGRAM (PROCEDURE PERFORMED 8Y RADIOLOGIST) INDICATION: Infertility for 15 years. Patient had one child 15 years ago. Last menstrual period was 1/13/20XX. No history of pelvic infection or surgery COMPARISON: None PROCEDURE: The examination and anticipated discomfort was discussed with the patient. A plastic vaginal speculum was introduced with the patient's legs in the stirrups following preliminary vaginal examination and lubrication. The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution. A 5F hysterosalpingogram catheter was used. The catheter balloon was inflated in the lower uterine segment. Fluoroscopic and radiographic assessments were done. The patient tolerated the procedure well. FINDINGS: Contrast was administered through the catheter and multiple images were taken. There is a possible abnormal contour to the right cornua with patchy contrast opacification which may represent intramural contrast with intravasation. No definite spillage of contrast from either fallopian tube was identified IMPRESSION: 1. Possible right cornual contour abnormality manifested by focal extravasation and minimal intravasation of undetermined etiology. Recommend endovaginal ultrasound for further evaluation. 2. No contrast filling of either tubes and no spill into pelvic peritoneal space. What are the CPT® and ICD-10-CM codes reported for this service?

58340, 74740-26; N97.9

A 32 year-old patient is coming into an outpatient facility to have a catheterization performed of the uterus with saline infusion sonohysterography due to dysfunctional uterine bleeding. A previous scan showed suspected endometrial polyps. What CPT® and ICD-10-CM codes are reported?

58340, 76831-26, N93.8 Rationale: The uterus is being catheterized not the bladder. Look in the CPT® Index for Sonohysterography/Saline Infusion/Injection Procedure directing you to 58340. The catheterization is included in the code description for 58340. A parenthetical note under this code states "For radiological supervision and interpretation of saline infusion, use 76831." Modifier 26 is reported for the professional service. The diagnosis to report is the dysfunctional uterine bleeding, which is found in the ICD-10-CM Alphabetic Index by looking for Bleeding/uterus, uterine NEC/dysfunctional of functional which guides you to code N93.8. According to ICD-10-CM guideline IV.H you do not code for a condition documented as suspected such as the endometrial polyps in the outpatient setting.

A 37 year-old has multilevel lumbar degenerative disc disease and is coming in for an epidural injection. Localizing the skin over the area of L5-S1, the physician uses the transforaminal approach under fluoroscopy guidance for needle positioning. The spinal needle is inserted, and the patient experienced paresthesias into her left lower extremity. The anesthetic drug is injected into the epidural space. What CPT® code(s) is/are reported?

64483 Rationale: In the CPT® Index look for Nerves/Injection/Anesthetic. You are referred to 01991-01992 or 64400-64530. You can also find this under Epidural/Injection/Transforaminal. Review the codes to choose the appropriate service. Code 64483 is the correct code because the anesthetic was injected into the epidural space in one single level (L5-S1) using the transforaminal approach. Imaging guidance is included in the procedure and not reported separately.

A patient presents to her physician with right eye pain, nasal airway obstruction, and deformity 48 hours after an assault. The physician orders an x-ray of the facial bones with a Waters view, Caldwell view, and a lateral view. What is the CPT® code for the X-ray?

70150 RATIONALE: Three views of the facial bones (Waters view, Caldwell view, and lateral view) were ordered. Look in the CPT® Index for X-ray/Facial Bones, 70140-70150. Code 70150 is for a complete, minimum of three views X-ray of the facial bones.

A contrast radiograph of the salivary glands and ducts is performed, resulting in a diagnosis of salivary fistula. What are the CPT® and ICD-10-CM codes for the supervision and interpretation of this procedure?

70390-26, K11.4 RATIONALE: Contrast radiography of the salivary gland and ducts is considered sialography. Code 70390 describes sialography supervision and interpretation. Look in the CPT® Index for Salivary Glands/X-ray/with contrast. The patient is diagnosed with a salivary fistula, which is found in the ICD-10-CM Alphabetic Index under Fistula/salivary duct or gland K11.4. Verify code selection in the Tabular List.

CASE 2 Location: Independent Diagnostic Testing Facility, radiologist employed by the facility. (Radiologist is employed by the facility, the IDTF will bill for global component.) CT BRAIN/HEAD W/WO CONTRAST EXAM: CT Head, without and with Contrast August 5, 20XX. COMPARISON: None available. HISTORY: Non-small-cell lung cancer. (Patient has non-small cell lung cancer, not specified to location in lung.) TECHNIQUE: Axial images of the calvarium without and with (CT performed without and with contrast.) 125 cc Omnipaque-300 intravenous contrast. (Contrast was intravenous.) FINDINGS: The calvarium is intact. Imaged upper portions of the maxillary antra show minimal mucosal thickening. The sphenoid ethmoid and frontal sinuses are clear bilaterally. No hydrocephalus, mass effect, brain shift, abnormal extra-axial fluid collection or mass. Calcification left basal ganglia without mass effect, nonspecific, likely benign. Abnormal but nonspecific decreased density in the periventricular and subcortical white matter of the cerebral hemispheres bilaterally without mass effect or enhancement, most consistent with remote microvascular ischemic change present to mild degree. Bilateral intracavernous carotid and vertebral arteriosclerotic calcification. Probable anterior communicating artery aneurysm 6 x 5 mm. Recommend intracranial CT angiography to further characterize. CONCLUSION: 1. No finding suggestive of metastatic disease. 2. Probable (Aneurysm is probable and would not be coded.) 6 x 5 mm anterior communicating artery aneurysm. Recommend intracranial CT angiography to further characterize. 3. Cerebrovascular arteriosclerosis. (Additional diagnosis of cerebrovascular arteriosclerosis.) 4. Nonspecific cerebral white matter lesions (Additional diagnosis of cerebral lesions.) most consistent with remote microvascular ischemic change. 5. Calcification left basal ganglia,(Additional diagnosis of calcification left basal ganglia.) likely benign; however, recommend continued imaging follow-up. What are the CPT® and ICD-10-CM codes reported for this service?

70470; C34.90, I67.2, G93.9, G23.8

A Computed tomography scan (CT) confirms improper ossification of cartilages in the upper jawbone and left side of the face of a patient with facial defects. A CT scan is performed with contrast material in the hospital. What CPT® code is reported by an independent radiologist contracted by the hospital?

70487-26 Rationale: The CT scan with contrast is performed on the maxillofacial area. The maxilla is the upper part of the jawbone. In the CPT® Index look for CT Scan/with Contrast/Maxilla directing you to 70487. Modifier 26 denotes the professional service.

A 41 year-old male is in his doctor's office for a follow up of an abnormality which was noted on an abdominal CT scan. He also had a chest X-ray (PA and lateral views) performed in the office due to chest tightness. He states he otherwise feels well and is here to go over the results of his chest X-ray performed in the office, and the CT scan performed at the diagnostic center. The results of the chest X-ray were normal. CT scan was sent to the office, and the physician interpreted and documented that the CT scan of the abdomen showed a small mass in his right upper quadrant. What CPT® codes are reported for the doctor's office radiological services?

71046, 74150-26 Rationale: The chest X-ray was taken in the doctor's office and interpreted. This means the doctor's office can bill for the code without appending a modifier. Modifier 26 is appended to the CT scan code, because, it was performed at another site and the physician only interpreted the image. Look in the CPT® Index for X-ray/Chest directing you to 71045-71048, and CT Scan/without Contrast/Abdomen directing you to 74150, 74176, and 74178. The correct code for the CT Scan is 74150.

Magnetic resonance imaging of the chest is first done without contrast medium enhancement and then is performed with an injection of contrast. What CPT® code(s) is/are reported for the radiological services?

71552 Rationale: The patient is having magnetic resonance imaging in which the images were performed first without contrast and again following the injection of contrast. In the CPT® Index look for Magnetic Resonance Imaging (MRI)/Diagnostic/Chest directing you to 71550-71552.

A patient needing scoliosis measurements is coming in to have standing anteroposterior and lateral views of his entire thoracic and lumbar spine. What CPT® code(s) is/are reported for radiology?

72082 Rationale: X-rays of the thoracic and lumbar (thoracolumbar) spine are being taken. In the CPT® Index look for X-ray/Spine/Thoracolumbar directing you to 72080, 72081-72084. Reviewing the code range in the Radiology Section, because anteroposterior and lateral, two views, of the spine are done for scoliosis, guides you to code 72082.

CASE 9 Location: Regional Hospital MRI OF THE LUMBAR SPINE History: Low back pain. Technique: On a 1.5 Tesla magnet multiple sagittal and axial images were performed through the 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. There is no central canal stenosis. There is no neural foraminal stenosis. At the L3-4 level, there is a minimal posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis. At the L4-S level, there is mild loss of disc height and loss of T2 disc signal. There is a moderate size right paracentral disc protrusion impinging the anterior aspect of the thecal sac. There is no central canal stenosis. There is no neural foraminal stenosis. At the L5-S1 level, there is no disc bulge or disc protrusion. There is no central or neural foraminal stenosis. IMPRESSION: Mild anterior wedging of the L3 vertebral body. It is uncertain whether this is acute or chronic finding. There is increased T1 signal involving the L2-3 disc which could be related to calcification or possible hemorrhage although this is felt to be less likely. Moderate size right paracentral disc protrusion at L4-5. Multilevel degenerative disc disease . What are the CPT® and ICD-10-CM codes reported for this service?

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

CASE 4 Location: Imaging center, radiologist employed.(Radiologist is employed by the imaging center: the imaging center should report the global component.) STUDY: FEMUR AP AND LATERAL(2 views taken.) REASON: LEFT LEG PAIN LEFT FEMUR: COMPARISON: There are no prior studies for comparison. FINDINGS: There is no fracture or dislocation of the left femur. The femoral head is concentrically seated within the acetabulum without deformity of the femoral head. IMPRESSION: Normal (Findings are normal, the reason for the study is used for the diagnosis.) views of the left femur. What are the CPT® and ICD-10-CM codes reported for this service?

73552-LT; M79.605

A 70 year-old female presents with a complaint of right knee pain with weight bearing activities. She is also developing pain at rest. She denies any recent injury. There is pain with stair climbing as well as start-up pain. AP, Lateral and Sunrise views of the right knee are ordered and interpreted. They reveal calcification within the vascular structures. There is decreased joint space through the medial compartment where she has near bone-on-bone contact, flattening of the femoral condyles, no fractures noted. The diagnosis is right knee pain secondary to underlying primary localized degenerative arthritis. What CPT® and ICD-10-CM codes are reported?

73562, M17.11 Rationale: Look in the CPT® Index for X-ray/Knee which directs you to 73560-73564, 73580. Code 73562 reports three views of one knee. The scenario is reported with one ICD-10-CM code. Look in the ICD-10-CM Alphabetic Index for Arthritis/degenerative which states to see Osteoarthritis. Look for Osteoarthritis/knee which guides you to code M17.1- A 4th character is reported for laterality. Report code M17.11 for the right knee. You do not report the ICD-10-CM code for knee pain as this is a symptom of the degenerative arthritis and included in the code.

A patient arrives at the hospital unable to stand on his leg after a collision in a soccer game. The patient's shin is sore to the touch. Two view X-rays of the tibia and fibula are taken. What is the CPT® code reported by the radiologist for the X-rays?

73590-26 Rationale: In the CPT® Index look for X-ray/Fibula, or X-ray/Tibia; either one leads you to 73590. Modifier 26 is needed because the X-ray is taken at the hospital and only the professional component is billed by the physician.

CASE 1 Location: Regional Hospital(Performed at the hospital, the radiologist will only code for the professional component.) CT THORAX W/CONTRAST,CT ABDOMEN W/CONTRAST,CT PELVIS W/CONTRAST,Low Osmolar Contrast (Three separate CT scan performed: Thorax (chest), Abdomen, Pelvis) EXAM: CT Chest with Contrast; CT Abdomen with Contrast; CT Pelvis with Contrast August 5, 20XX. COMPARISON: CT chest Regional Hospital 7/8/20XX. HISTORY: Non-small-cell lung cancer. (Pt has non-small cell lung CA.) TECHNIQUE: Axial images of the chest, abdomen pelvis with oral and 125 cc Omnipaque-300 intravenous contrast. (Contrast used.) FINDINGS: Chest CT (Chest CT findings.) shows left upper (Mass is in the left upper lobe.) lobe and pulmonary mass which appear centrally necrotic abutting the posterior pleural surface and mediastinum without definitive invasion, 83 x 64 mm, prior 76 x 56 mm, image 15. Stable lingular and left basilar, right middle lobe and right lower lobe superior segment pleural-parenchymal opacity suggesting scarring. New mild subsegmental infiltrate left upper lobe. No pneumothorax or pleural fluid. No thoracic adenopathy. Heart size normal, no pericardial effusion. Left coronary arteriosclerotic calcification present. No osseous neoplasm. Abdomen CT (Abdomen CT findings.) shows normal liver, gallbladder, biliary ducts, pancreas, spleen, adrenal glands and kidneys. Stomach and duodenum within normal limits. Aortoiliac arterial sclerosis without aneurysm. No retroperitoneal adenopathy. Pelvis (Pelvis CT findings.) CT shows no mass, adenopathy or ascites. No bowel obstruction. No hernia. No osseous neoplasm. Lumbar spine degenerative change present. Left-sided muscle atrophy and brace noted. Conclusion: 1. Increasing size left upper lobe pulmonary mass (The mass is part of the lung CA.) with central cavitation suggested. 2. No thoracic adenopathy or distant metastatic disease demonstrated. 3. Coronary arteriosclerosis. (Secondary diagnosis of coronary arteriosclerosis.) What are the CPT® and ICD-10-CM codes reported for this service?

74177-26, 71260-26; C34.12, I25.10

CASE 6 Location: Regional Hospital EXAMINATION: 1. CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT ABDOMEN - NEUTRAL ENTERAL WITH IV CONTRAST- 2D REFORMATS) 2. CT ENTEROCLYSIS (FLUORO ENTEROCLYSIS WITH CT PELVIS - NEUTRAL ENTERAL WITH IV CONTRAST - 20 REFORMATS) Clinical Indication: Unexplained abdominal pain and diarrhea, as well as weight loss. Normal colonoscopy. Comparison: None. PROCEDURE: In accordance with policy and procedure standard medication reconciliation was performed by the radiologic technologist prior to IV contrast administration. No contraindication was identified. The examination was performed in accordance with the standard protocol on a 43 year-old male. Following preprocedure assessment, informed consent was obtained. Conscious sedation Independent observation performed by Amy Smith, RN. Total Time of Sedation: 60 minutes. Vital signs, pre-procedure and post-procedure monitoring were done by nurse in attendance with me performing the conscious sedation. A transnasal intubation was done following a nasal drop of a local anesthetic. Under fluoroscopic guidance, using guidewire and positional maneuvers, the enteroclysis catheter was advanced and the tip anchored at the distal horizontal duodenum. Neutral enteral contrast was infused and monitored to a total of approximately 3.5 L. 0.6 mg Glucagon was administered IV prior to IV contrast administration. CT acquisition was done during continued infusion of enteral contrast following a 45 to 50 seconds delay. Intravenous administration of 100 ml lsovue 370 at 4 ml/second infusion rate. CT parameters used were 40 x 0.625 mm collimation reconstructed at 2 mm section thickness reconstructed at 1 mm intervals. The source images were transferred to an independent workstation (EBW) and cross referenced multiplanar interactive 2D interpretation was done by the radiologist. Images were reviewed using soft tissue window settings. Following completion of the infusion, the catheter was withdrawn into the stomach and refluxed contrast removed prior to catheter removal. No acute adverse events occurred. FINDINGS: There is no evidence of transmural inflammatory disease changes involving the small bowel or the colorectum. There is, however, mild prominence of the vasa recta in the right lower abdomen, mild increased attenuation of the cecum and ascending colon and adjacent distal small bowel. Suggest biopsy at the ascending colon to exclude microscopic colitis. If the patient has a history of blood in the stools, air double-contrast enteroclysis would be of value to exclude aphthous ileitis. CT enteroclysis may not be able to assess for early Crohn's until transmural involvement is seen. The rest of the colon also appears normal. There are no fold changes to suggest adult celiac disease. There is no evidence of a small bowel mass. The mesentery appears normal. Solid abdominal organs are grossly unremarkable. IMPRESSION: 1. No evidence of transmural inflammatory disease changes involving the small bowel or colorectum. No fold abnormalities to suggest sprue. 2. Prominence of vasa recta of cecum and ascending colon and distal ileum with question of mild increased attenuation. Consider microscopic colitis. See discussion and recommendation above. If there is strong clinical suspicion of Crohn's disease, consider air DC barium enteroclysis to exclude or confirm early aphthoid changes. 3. Reproduction of abdominal pain during contrast infusion, thus, correlated for visceral hypersensitivity. 4. Solid abdominal organs grossly unremarkable. What are the CPT® and ICD-10-CM codes reported for this service?

74177-26, 74340-26, 44500, 99152, 99153x3; R10.9, R19.7, R63.4

A young child is taken to the OR to reduce a meconium plug bowel obstruction. A therapeutic enema is performed with fluoroscopy. The patient is in position and barium is instilled into the colon through the anus for the reduction. What CPT® code is reported by the independent radiologist for the radiological service?

74283-26 Rationale: A therapeutic enema was performed with contrast (barium) to reduce the meconium plug (intraluminal obstruction). In the CPT® Index look for Enema/Therapeutic/for Intussusception directing you to 74283. The code description includes therapeutic enema with contrast for intraluminal obstruction. Modifier 26 denotes the professional service.

A parent brings her child to the ED. She thinks she swallowed a small toy figure. A radiology exam from the nose to the rectum is performed. The foreign body is not located. What CPT® code(s) is/are reported for the radiology services?

76010 Rationale: The radiology exam is performed to locate a foreign body, yet no foreign body is found. In the CPT® Index look for X-ray/Nose to Rectum/Foreign Body. The correct code is 76010.

During a physical examination hepatomegaly is revealed. The physician orders an ultrasound of the liver to evaluate the hepatomegaly. What CPT® code is reported?

76705 Response Feedback: RATIONALE: Ultrasound of the abdomen includes the liver, gall bladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. Because the ultrasound was of only the liver, it is considered a limited abdominal ultrasound. Look in the CPT® Index for Ultrasound/Abdomen.

CASE 5 Location: Regional hospital. (Provided at the hospital, the radiologist will report the professional component.) Study: Ultrasound Urinary Tract Indications: Status ureteral reimplantation (The surgical procedure has been performed. The ultrasound is being performed after a surgical procedure for evaluation of continued reflux.) to evaluate for continued vesicoureteral reflux. Left Kidney:(Kidney evaluated.) Length: 7.0 cm Prior length: 7.4 cm Parenchyma: Cortical scarring. Pelvic dilatation: Normal Calyceal dilatation: Normal Hydronephrosis grade: Normal Interval hydronephrosis change: None Right Kidney: Length: 6.6 cm Prior length: 6.4 cm Parenchyma: Cortical scarring. Pelvic dilatation: Normal Calyceal dilatation: Normal Hydronephrosis grade: Normal Interval hydronephrosis change: None Ureters: (Ureters evaluated.) Normal Bladder: (Bladder evaluated.) Almost empty and difficult to evaluate. Impression: 1, Interval right renal enlargement without hydronephrosis. (Diagnosis—right renal growth.) 2. Stable asymmetric small left renal size (Additional diagnosis—small left renal size.) likely to represent diffuse cortical scarring. What are the CPT® and ICD-10-CM codes reported for this service?

76770-26; Z48.816, N13.70, N28.81, N27.0

A complete B-scan ultrasound without duplex Doppler of the kidney is performed in the physician's office on a patient following a kidney transplant. What is the CPT® code for the ultrasound?

76775 RATIONALE: Look in the CPT® Index for Ultrasound/Kidney, 76770-76776. CPT® code 76776 is an ultrasound for a transplanted kidney, including real-time and duplex Doppler with image documentation. A duplex Doppler of the kidney is not performed. The parenthetical instruction under CPT® 76776 indicates to report 76775 for an ultrasound of transplanted kidney without duplex Doppler. The correct code is 76775.

A patient 14 weeks pregnant is coming back to her obstetrician's office for a repeat transabdominal ultrasound to measure fetal size and to confirm abnormalities seen in a previous scan. The obstetrician documented the ultrasound results in the medical record. What CPT® code is reported by the obstetrician?

76816 Rationale: The patient is coming back for a follow-up (repeat) ultrasound to re-evaluate conditions affecting the fetus seen on the last ultrasound scan. In the CPT® Index look for Ultrasound/Obstetrical/Pregnant Uterus to find the code range 76801, 76802, 76805, 76810-76817. The correct code for a follow-up ultrasound is 76816. No modifier 26 is needed because the ultrasound and the interpretation of the results were performed in the obstetrician's office.

A non-Medicare patient reports for a bilateral screening mammography with CAD. What CPT® code(s) is/are reported?

77067 Rationale: In the CPT® Index look for Mammography/Screening Mammography and you are guided to 77067.

CASE 3 Location: Imaging center; radiologist employed.(Radiologist is employed by the imaging center: the imaging center should report the global component.) STUDY: MAMMOGRAM BILATERAL SCREENING,(Screening bilateral mammogram.) all VIEWS, PRODUCING DIRECT DIGITAL IMAGE REASON: SCREEN BILATERAL DIGITAL MAMMOGRAPHY WITH COMPUTER-AIDED DETECTION (CAD) (Use of CAD.) No previous mammograms are available for comparison. CLINICAL HISTORY: The patient has a positive family history of breast cancer.(Family history of breast CA.) Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system. FINDINGS: Residual fibroglandular breast parenchymal tissue is identified bilaterally. No dominant spiculated mass or suspicious area of clustered pleomorphic microcalcifications are apparent. Skin and nipples are seen to be normal. The axilla is unremarkable. IMPRESSION: BIRADS 1 - NEGATIVE(Negative screening.) What are the CPT® and ICD-10-CM codes reported for this service?

77067; Z12.31, Z80.3

A patient with osteoporosis reports to her physician's office for a DXA bone density study of her spine to monitor the severity of her condition. What is the correct CPT® code for the DXA scan?

77080 RATIONALE: DXA is dual-energy X-ray absorption. The site is of the spine, which is part of the axial skeleton. For DXA-See Dual X-ray Absorptiometry (DXA); Dual X-ray Absorptiometry (DXA)/Axial Skeleton. In this case one site (spine) is involved in the study. The correct code is 77080.

A patient on estrogen replacement therapy (ERT) receives a DXA study of the hips. What is the CPT® code reported for the bone density study?

77080 Rationale: In the CPT® Index look under Bone Density Study/Axial Skeleton/Dual Energy X-ray Absorptiometry (DXA) and you are directed to 77080, 77081, 77085. Review in the numeric section shows 77080 for axial skeleton is the correct code for reporting DXA study of the hips.

A 65 year-old female has a 2.5 cm x 2.0 cm non-small cell lung cancer in her right upper lobe. The tumor is inoperable due to severe respiratory conditions. She will be receiving stereotactic body radiation therapy under image guidance. Beams arranged in 8 fields will deliver 25 Grays per fraction for 4 fractions. What CPT® and ICD-10-CM codes are reported?

77373, Z51.0, C34.11 Rationale: Patient is having stereotactic radiation therapy technique delivered, not managed, in a large radiation dose to tumor sites in the upper right lobe of the lung. In the CPT® Index look for Radiation Therapy/Stereotactic Body which directs you to 77373. Codes 77371-77373 do not need modifier TC or 26, because they are facility only codes. 77373 is correct with stereotactic body radiation not exceeding 5 fractions. According to ICD-10-CM guideline I.C.2.a. "If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.-code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis." In the ICD-10-CM Alphabetic Index look for Encounter/radiation therapy (antineoplastic) which directs you to Z51.0. In the ICD-10-CM Table of Neoplasms look for Neoplasm, neoplastic/lung/upper lobe and select from the Malignant Primary column referring you to C34.1-. Verification in the Tabular List indicates a 4th character is needed, report 1 for the right lung.

A patient with prostate cancer has his first dose of radiation treatment of a single area that requires a single port and an energy level of 7 milli-electron volts (MeV). What CPT® code is reported?

77402 Rationale: A patient with prostate cancer is receiving radiation treatment delivery by port of a single treatment area. In the CPT® Index look for Radiation Therapy/Treatment Delivery directing you to 77401, 77402, 77407, 77412. Upon verification code 77402 is the only code that represents a single treatment area with 7 MeV of energy.

A male patient being treated for prostate cancer receives brachytherapy treatment. Twelve radioactive seeds are interstitially applied within the prostate. What is the CPT® code for the radiological component?

77778 RATIONALE: In this case, brachytherapy is performed using interstitial application of radiation seeds. According to the Radiology Guidelines, a complex application has greater than 10 sources, which is reported with code 77778. Review the CPT® coding guidelines for the definition of simple, intermediate, and complex for clinical brachytherapy. Look in the CPT® Index for Brachytherapy/Interstitial Application 0395T, 77778.

A 1 year post-thyroidectomy patient who had thyroid cancer is coming in for area imaging of the neck and chest to evaluate for metastases. What CPT® code(s) is/are reported for the nuclear medicine exam?

78015 Rationale: The patient is having thyroid imaging for carcinoma (cancer) metastases limited to the chest and neck only. A thyroid uptake is a test to measure the thyroid function in determining how much iodine will be absorbed by the thyroid. This is not performed therefore add-on code 78020 is not reported. In the CPT® Index look for Nuclear Medicine/Diagnostic/Thyroid/Imaging for Metastases directing you to 78015-78018. 78015 is the correct code for limited area imaging.

Procedure: Body PET-CT Skull Base to Mid-thigh History: A 65 year-old male Medicare patient with a history of rectal carcinoma presenting for restaging examination. Description: Following the IV administration of 15.51 mCi of F-18 deoxyglucose (FDG), multiplanar image acquisitions of the neck, chest, abdomen and pelvis to the level of mid-thigh were obtained at one hour post radiopharmaceutical administration. What CPT® code(s) is/are reported?

78815 Rationale: The procedure performed is a PET-CT scan. The appropriate code is selected based on the anatomical location of the study. In this scenario, we know the test was performed on the skull base to the mid-thigh. In the CPT® Index look for Nuclear Medicine/Diagnostic/Positron Emission Tomography (PET)/with Computed Tomography 78814-78816. 78815 is skull base to mid-thigh. According to CPT® coding guidelines, the IV administration of FDG (96365) is not reported separately. It is bundled in the service for the radiology procedure.

CASE 8 Location: Regional Hospital EXAM: Renal and bladder ultrasound dated 10/01/20XX Renal artery Doppler evaluation dated 10/01/20XX COMPARISON: Renal MRA dated 04/01/20XX HISTORY: 80-year-old with renal artery stenosis. Diagnostic ultrasound of the kidneys was ordered to see if there was kidney damage due to the renal stenosis or other kidney issues. This was followed after review with a renal Doppler study. FINDINGS: Multiple grayscale sonographic and color Doppler images of the kidneys and renal vasculature were submitted for interpretation. The right kidney measures 10.1 cm without evidence of pelvic caliectasis. There is a small 8mm cyst noted within the lower pole of the right kidney. There is relatively normal internal architecture and echogenicity. The left kidney measures 10.4 cm with no evidence of pelvicaliectasis. There are at least 3 renal cysts identified, the largest measuring 2 cm in diameter. There is normal internal architecture and echogenicity. The bladder is distended with urine and appears within normal limits. The aorta demonstrates peak systolic velocity of 1.07 m/sec. The right renal artery origin demonstrates peak systolic velocity of 3.0 m/sec with a resistive index of 0.92. The midportion of the right renal artery demonstrates a peak systolic velocity of 1.1 m/sec with resistive index of 0.8. The right renal hilum has a peak systolic velocity of 0.64 m/sec with resistive index of 0.85. The inferior pole has a systolic velocity of 0.16 m/sec with resistive index of 0.54. The midpole has a systolic velocity of 0.18 m/sec and resistive index of 0.70. The superior pole has a velocity peak of 0.22 m/sec with a resistive index of 0.77. The left renal artery origin demonstrates a peak systolic velocity of 2.0 m/sec with a resistive index of 0.87. The mid portion of the left renal artery demonstrates a peak velocity at 0.42 m/sec and a resistive index of 0.80. The left renal hilum has a peak systolic velocity of 0.47 m/sec and a resistive index of 0.82. The inferior pole has a systolic velocity of 0 16 m/sec and a resistive index of 0.67. The midpole has a systolic velocity of 0.17 m/sec and a resistive index of 0.63. The superior pole has a velocity peak of 0.13 m/sec with a resistive index of 0.69. IMPRESSION: RENAL ARTERY DOPPLER STUDY: 1. Moderate stenosis of the right renal artery origin. 2. Mild to moderate left renal artery origin stenosis. RENAL AND BLADDER ULTRASOUND: 1. Bilateral probable renal cysts. 2. Normal appearing bladder What are the CPT® and ICD-10-CM codes reported for this service?

93976-26, 76770-26-59; I70.1

Which plane divides the body into anterior and posterior halves?

Coronal Rationale: The frontal (coronal) plane cuts the body into front (anterior) and back (posterior) halves.

Which anatomic position has the patient lying at an angle instead of lying flat or directly on their side?

Oblique Rationale: The oblique position is a slanted position where the patient is lying at an angle that is neither prone nor supine.

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?

R93.0, J32.9, J38.01 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 J32.9. The last code is found in the Alphabetic Index under Paralysis/vocal cords /unilateral J38.01. Verify code selection in the Tabular List.

The axial plane divides the body into what sections?

Superior and inferior RATIONALE: The axial plane, also known as the transverse plane, slices the body horizontally and cuts the body into inferior and posterior sections.

What ICD-10-CM code is reported for an adverse effect to diagnostic iodine, initial encounter?

T50.8X5A Rationale: Look in the ICD-10-CM Table of Drugs and Chemicals for Iodine/diagnostic. Report the code from the Adverse Effect column T50.8X5. In the Tabular List, T50.8X5 requires a seventh character. A is reported for the initial encounter.

In ICD-10-CM when a patient is seen for a routine examination, what additional information is needed in order to accurately code the routine examination?

Whether or not abnormal findings were identified. Rationale: In ICD-10-CM the codes for radiologic exam have been expanded to specify when abnormal findings are found on the radiology exam. 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. Z00.00 Encounter for general adult medical examination without abnormal findings. Z00.01 Encounter for general adult medical examination with abnormal findings.