Chapter 5 (p. 171)
Radiology
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Subsections
Dx Radiology (Imaging), Dx Ultrasound,
Radiologic Guidance, Breast, Mammography
Bone/Joint Studies, Radiation Oncology
Nuclear Medicine (X-Rays, CT, MRI, MRA, etc)
Example: See family practice Dr. for broken toe. She sends
you to hospital for x-ray.
Pt has x-ray at hospital read by radiologist. Report goes
to family practice Dr. who reads it. She only bills for the
original office visit (E/M level).
Anatomical Site, Type of Radiology, Head-to-Toe
Use this to shop or use Index
Now there is a facility claim (UB-04), 837i
CMS-1450 outpt x-ray: CPT (alone, no modifier)
This is facility and they can only do the Technical component.
Profees are not claimed on CMS-1450 form. Medicare A
Pay attention to Notes in front of subsections.
Hospital Billing and Radiology Code Reporting
Most of these codes are Chargemaster driven.
Tbl 5.1:
Charge Seq # is specific to the hospital
Revenue Center # is CMS' Department Acct (Huge Manual)
CPT Code matches the Hospital Description posted
Coders need to see all the charged codes to know how to
apply modifiers. If any part of that is hidden bcs Radiology
sends codes to billing, then Coders need to push to get more
transparency.
Keeping Chargemaster Updated
The HI Director can have a large part of this or there may
be 1 or 2 people in charge of just this.
All changes must be reviewed so they can be updated at
least annually. When new equipment or procedures are
introduced, the Chargemaster should also be updated.
Errors in Chargemaster can cause denials. Inappropriate
unbundling of codes can result in fraudulent charges to
insurance companies. This is an important data quality
concern.
Physician Billing
Technical Component: The cost of doing the exam for
doing the procedure (equipment, film, radiology tech/staff).
Professional Component: Physician's part of the bill for
reading/interpreting the test and dictating the report.
-- If a radiology service is performed in a physician's office or
a freestanding center owned by the radiologist, using form
CMS-1500 (837p) communicate to the payer that this is the
Technical Component or the Professional Component.
Just use CPT code with no modifier
-- If the radiology center only does one portion or the other:
Radiology component only: CPT-TC (HCPCS II modifier)
Professional Fees only: CPT-26
 if CPT code alone, this tells CMS this is for both Technical
and Profee
CPT-26 tells CMS only to reimburse for reading/interp.
CPT-TC tells CMS to reimburse only for the cost of doing
the exam.
CMS 1500 for the radiologist services
CPT-26 (professional component)
2nd Opinion
 --Radiologist says they are not sure, wants a 2nd
opinion...
On the 2nd opinion claim put on modifier -26
 --Some insurance companies, tho, also want modifier 26-77 (Repeated Procedure by Other Physician)
 --Other insurance companies want CPT 76140 for 2nd
provider. (Consult)
 --May need to call payer to find out how they want it
submitted.
Example: 3 View X-ray of Hand and 3 View X-ray of Wrist
(40 minutes on tape)
Radiology could do 3 films of hand: 73110
and
3 films of wrist: 73130
but they will probably instead charge Pt for 1 set of films
3 pics of hand (including wrist -- same site)
Hospital bills 73130-RT
which saves the cost of 3 more films.
The profees get billed as bcs Radiologist reads films twice,
once for hand and once for wrist and MUST submit 2
separate reports.
73110-26-RT
73131-26-RT
This used to be a similar problem with Abdomen and Pelvis
CTs where the pelvis was included in the picture when the
abdomen was viewed and vice versa. Now there are
combination codes (see Tbl on pg. 402 CPT manual)
This eliminates the 2nd Profee submitted by physician!
Contrast Material (p. 175) (50 minutes)
CPT code book differentiates btwn radiologic procedures with
and w/out contrast material. Contrast materials (radiopaque
substances) block passage of x-rays causing white to appear
on film.
Chapter 5 (p. 171)
Radiology
Sometimes the exam is done without contrast first and then
with contrast to form a baseline.
If contrast is given thru IV (Intravenous), Joint (intraarticular), Spine (intrathecal) then code with contrast
If contrast is given orally or rectally (GI tract) code
without contrast.
If injected through joint of spine, code the procedure for the
injection of contrast. Same for joint injections of contrast.
When requirements are met, reimbursement for the supply
of contrast media may be obtained by reporting the
appropriate HCPCS Level II code. If not CMS claim, may code
for supplies: 99070 (for everything except eye glasses). Chris
says don't bother for her, but payers may allow it.
Admin. of Contrast Materials, Radiology Guidelines
(CPT Manual, pg. 393)
Intra-articular injections:
Use appropriate joint injection code
Radiographic arthrography:
include arthrography supervision and interpretation code
for the approp. joint (which includes fluoroscopy).
CT or MRI arthrography:
appropriate joint injection code
appropriate CT or MR code w/ or w/out contrast
appropriate imaging guidance code for needle placement
for contrast injection.
Spine exams `with contrast' includes intrathecal (61055 or
62284) for intravascular injection.
Intravascular Injection may be used with CT, CT angiography
(CTA), MRI, and MRA procedures
Oral and/or Rectal contrast administration alone does not
qualify as "with contrast".
Sometimes contrast is inherent in some procedures, such as
IVP or hystosalpingogram. Do not code contrast here.
Radiological Supervision & Interpretation (p. 173)
GUIDANCE
A Complete Procedure usually has 2 Physicians perform
different portions of this procedure. A Surgical
Component and a Technical Component (Radiology
here).
Example:
Needle biopsy of the liver (47000). Needle thru skin into
liver to get liver tissue. This tissue is sent to pathology
for interpretation. There is a surgical code for the
procedure. There is also a radiology guidance code (CT,
Ultrasound, X-ray) for guidance (77012) (CPT p. 417).
Ultrasonic Guidance (p. 416) is separate from the other
radiological guidance (47000 + 76942). One code for
needle biopsy, but 2 choices for radiological portion,
have to choose the correct one to use.
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Example:
Needle biopsy with CT guidance. After biopsy, while pt is still
in CT, they scanned the entire area.
47000 + 77012 + code for the entire area, but only if the
whole area is reviewed in report.
This can be viewed as a component situation where you have
a code for a large procedure and a portion of that
procedure is being included. Will probably have to use
modifier -59 to show the biopsy guidance is separate and
distinct.
Modifiers:
-52 (contrast to -73 and -74). Reducing/stopping a procedure
that does not use anesthesia.
CT codes can use -52 if a limited study or follow-up study is
done.
CT study of the abdomen (74150-52) without contrast,
focusing only on 1 or 2 organs. This is not a complete
procedure.
Complete vs Limited (p. 177)
Dx Ultrasound, Abdomen and Retroperitoneum Notes
(CPT p. 413) defines complete. Ultrasound does not use
-52 because it allows options of complete or limited
procedures, where other radiology sections do not.
Those others will require a -52 modifier for reduced
services.
"All other areas are as expected" qualifies as reviewing the
whole area for a complete examination. Limited is rare.
-59 Distinct Procedural Services: Need to have something
documented to backup the use of this code.
GG: (Shirt On) Performance and payment of Screening
Mammogram (they send you home, then call you back
for) Dx Mammogram on same pt on same day.
GH: (Shirt Off) Dx Mammogram converted (before you leave)
from screening Mammogram on same day
Breast, Mammography (CPT, p. 419) (77051-77059)
Computer Aided Detection: requires 2 codes
Screening = No signs or symptoms. You are there because
you are asymptomatic, but checking or you have risk
factors.
Diagnostic = something is going on (lump, dimpling, lesion,
calcification, nipple inversion)
ABN process on screening mammograms to limit them. Few
restrictions on Diagnostic mammograms.
Beware "screening mammography, lump". This is not a
screening. The symptom makes this diagnostic.
Chapter 5 (p. 171)
Radiology
A CMS claim for a unilateral mammogram should be modified
to show left or right (RT or LT). Bilateral is part of code
description, so no modifier.
There is only one screening code and it defaults to bilateral.
Previous mastectomy long ago, now having screening
mammogram modified with 77057-52 for reduced
services.
If pt had screening mammogram, went home and came back
same date of service: 77057 + 77056-GG
If converted directly from screening to diagnostic: 77056-GG
CMS requires HCPCS codes instead of CPT codes (level II
codes instead of level I codes)
G0202, G0204, G0206 with narratives the same as CPT
codes. If using Computer Aided Technology, use these
'G' codes and add the 77051 or 77052 codes, too.
(Not on test) The FI or MAC may determine how these
codes are used.
Interventional Radiology: Very high-tech stuff.
See Appendix L. Too complicated for us. Has to do with
injecting, with a catheter, into the vascular system.
Know main, intermediate, and lower levels of vascular
system.
Some Ultrasound falls in the Medicine section: Echoes,
Arterial and venous studies.
Diagnostic Ultrasound (Radiological Section)
(76801-76810) (p. 414)
Pregnancy related Ultrasound: Condition of pregnancy.
Test is usually ordered as nongravid (76856) unless a
pregnancy is found. Then pregnancy codes should be
looked at. The results of the exam determine which
way to code.
76810 vs 76816
Twins
76805 + 76810
Triplets
76805 + 76810 + 76810
Single
Twins
Triplets
76816
76816 + 76816-59
76816 + 76816-59 + 76816-59
Radiation Oncology
Hardest part is getting documentation. When you have it, it
is very detailed and easy to code and chargemaster
driven.
Nuclear Medicine
Radioactive isotopes need to be separately reported with
HCPCS Level II code for CMS Pts.
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