The field of diagnostic radiology comprises a diverse range of services, such as diagnostic radiology (plain film), diagnostic ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), diagnostic nuclear medicine, positron emission tomography (PET), and mammography. In light of the increasing scrutiny of imaging services by both public and private payers, it is imperative that coders adhere to accurate CPT® coding guidance as per the instructions of various authoritative bodies, including the American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and American College of Radiology (ACR).
It is essential to bear in mind that the rules of each individual payer take precedence when submitting claims. Therefore, it is advisable to request payer requirements in writing and ensure that billing and coding personnel are well-versed in all payer regulations.
Tip 1: Ensure Reports Meet Minimum Standards
To comply with ACR guidelines, diagnostic imaging reports must consist of the following components:
– Patient demographics
– Relevant clinical information
– Body of report (findings)
– Impression (conclusion or diagnosis)
– Physician signature
– Diagnostic studies (plain films)
Note: A resolution adopted by ACR in 2021 stipulates that nonphysicians, whether working under physician supervision or as independent nonphysician healthcare providers, should not be allowed to interpret medical imaging studies.
Tip 2: Differentiate Professional and Technical Aspects
Most radiology procedures comprise both technical and professional aspects. As a fundamental rule of radiology coding, coders must determine whether to report a technical, professional, or global service. The technical component of a service encompasses all equipment, supplies, personnel, and expenses involved in conducting the exam. To report only the technical aspect of a service, append the modifier “TC.”
An exception to the standard protocol pertains to services rendered within a hospital setting. It is typically assumed that the technical component of each study is billed by the hospital itself, thereby exempting them from the requirement to report modifier TC.
The professional component of a service includes the physician’s contribution to providing a dictated report or report supervision. To solely report the physician’s work portion in a service, it is necessary to append modifier 26 Professional component. When utilizing modifier 26, it should be placed in the primary designated modifier field since it holds a significant impact on the payment procedure.
A global service refers to the situation where the physician bears the cost of equipment, supplies, and other necessities, in addition to supervising and/or preparing the report. Global services are typically conducted in-office settings where the physician group owns the equipment and provides dictated reports. Modifiers TC and 26 are not mandatory while reporting global services.
For example, if a radiologist reads a two-view chest X-ray within the hospital, you will report 71046 Radiologic examination; chest, 2 views with modifier 26. If the radiologist’s office supplies the equipment with which the X-ray is performed, you will report 71046 without a modifier.
Tip 3: Accurately Record the Number of Documented Views
It is essential to ensure that the reported number of views aligns with the fundamental requirements of the relevant CPT® code. Utilizing a predetermined list of standard views or a set number of views for imaging purposes in your department or office is not admissible for coding purposes. The medical report must explicitly state the number of views, and it is the responsibility of the coder to accurately count the views and choose the appropriate corresponding CPT® code.
For instance, a knee examination may be coded using one of the four CPT® codes. To report 73564 Radiologic examination, knee; complete, 4 or more views, the documentation must substantiate the existence of four or more views. If the physician fails to specify the number of views, but instead reports “AP, lateral, and both obliques,” such documentation is acceptable. If, however, the physician uses the phrase “multiple views of the knee,” the rules state you must report the lowest-level corresponding CPT® code for that study.
The proper documentation of referring physician orders is crucial to ensure that radiology department standards are met. If the views or their number are not specified, the department cannot impose any set standards. Rather, it is essential to communicate with the referring physician and request a new order that clearly indicates the specific views required for accurate diagnosis. It is important to note that some diagnostic studies require distinct view names. In cases where the physician indicates the number of views instead of their precise names, the lowest-level code for that service must be reported.
Tip 4- Differentiate between a scout view and contrast studies.
A scout view is a single supine view of the abdomen taken before GI examinations, also known as KUB. The physician must document that the film was taken and any findings must be dictated separately.
Note: A cervical (neck) esophagram study is bundled to single and double upper GI studies; however, if there is documented medical necessity to warrant a separate exam, the esophagus study (74210-74230) may be reported with modifier 59 Distinct procedural service, in addition to the upper GI studies.
When submitting a report for a barium enema (colon) study, it is essential to ascertain whether the procedure involved the use of single or double contrast. The inclusion of a preliminary abdomen KUB (kidney, ureter, bladder) examination has no impact on the applicable code set.
For certain gastrointestinal (GI) studies, such as those described by CPT® codes 74328, 74329, and 74330, “supervision and interpretation” are explicitly stated as part of the code descriptors. This indicates that a physician may perform the procedure while a radiologist interprets the results. In such cases, both parties may submit a claim for their respective services by appending modifier 52 Reduced services to the appropriate CPT® code. The use of this modifier informs the payer that neither the physician nor the radiologist provided the complete service.
It is imperative that all diagnostic ultrasound examinations are accompanied by permanent image documentation. In particular, abdomen and retroperitoneal studies must adhere to strict documentation requirements in order to be coded as complete exams.
Tip 5- Differentiate between Complete and Limited Exam
To qualify as a complete abdomen study (76700 Ultrasound, abdominal, real time with image documentation; complete), documentation of several anatomies is mandatory. These include the liver, gall bladder, common bile ducts, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. Failure to document any of these structures will result in a downcoding to a limited exam (76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)).
The comprehensive evaluation of the retroperitoneum (76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real-time with image documentation; complete) encompasses the documentation of the kidneys, abdominal aorta, and common iliac artery origins. However, in cases where the clinical indication for the exam pertains to urinary pathology, imaging of the kidneys and urinary bladder is also considered a complete retroperitoneal study.
Tip6- Differentiate between Oral and Intravenous Contrast
It is crucial to note that for CT and MRI, coding depends on whether intravenous contrast was administered. The administration of oral and/or rectal contrast does not warrant billing as a “with contrast” study. To properly report contrast in these cases, the dictated report must specify the use of intravenous contrast in the technique section.