ACR Radiology Coding Source™ Nov-Dec 2004 Q and A

Q: What is the correct code to use for a standing film that includes both legs from hips to ankles as AP legs on a 14X36 cassette for such indications as Legg Perthes disease and leg length discrepancies? Is it appropriate to use 76040 (bone length study) even though the study is performed standing and no ruler is used, or should 73565 be reported instead?

A: The appropriate code to use to describe a study performed for such indications as Legg Perthes disease (a disease of bone growth) is 76040 (Bone length studies (orthoroentgenogram, scanogram)). The bone length study, performed for bone length or growth discrepancy, does not require a quantitative assessment of length, and the fact that the patient is standing and a ruler is not used should not deter from the use of this code. Assuming that the standing view is obtained at 6' rather than at 40", it is possible to make direct measurements on the film without a ruler to correct for magnification.

Code 73565 (Radiologic examination, both knees, standing, AP) is used for a standing view of both knees from which morphology (form and structure) is reported. If both studies are medically necessary and are both performed, it is appropriate to code for both.

Q: How do you code for the brachytherapy seeds in the office (freestanding) setting as of January 1, 2005 when CPT code 79900 is deleted?

A: With the deletion of CPT® code 79900 (Provision of therapeutic radiopharmaceutical(s)), it is appropriate to report HCPCS code Q3001 (Radioelements for brachytherapy, any type, each). CMS announced in the Medicare Physician Fee Schedule 2005 Final rule that it is reinstating HCPCS code Q3001 under the physician fee schedule and that it will be carrier priced (Reference. Nov. 15, 2004, Federal Register, Vol. 69, No. 219, p. 66370). In the hospital outpatient setting, the appropriate HCPCS Level II C code should be used.

Q: How do you code for a "midline catheter" (similar to a PICC line) when it terminates in the subclavian vein?

A: A central venous access device is described in the Current Procedural Terminology (CPTâ) book as a catheter or device terminating in the subclavian, innominate or iliac vein, the superior or inferior vena cava, or the right atrium. Accordingly, a peripherally inserted catheter terminating in the subclavian vein fulfills these strict criteria and would be appropriately coded using one of the central venous access procedure codes described as Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump. Depending upon the patient's age, this service should be coded as 36568 (under 5 years of age) or 36569 (age 5 or older).

"Midline catheter" is used by many different individuals to describe different types of peripheral lines, some terminating in the chest, and some in a peripheral vein. More important than the title given to the catheter is the exact anatomic position of the catheter, which can only be determined from careful review of a well-dictated report.

The structure of the CVA surgical codes is organized by: the type of procedure performed (i.e., insertion, repair, partial replacement, complete replacement or removal of a central venous device), the type of device employed in the procedure (e.g., non-tunneled central venous catheter, tunneled central venous catheter), the method of insertion [centrally inserted (jugular, subclavian, femoral vein or inferior vena cava catheter entry site) or peripherally inserted (e.g., basilic or cephalic vein)], and device access, i.e., via the use of a port or pump or via an exposed catheter. It should be noted that no distinction is made between how venous access is achieved (percutaneously or by cutdown), and no distinction is made based on catheter size.

The patient's age is used to differentiate some of the procedures, because pediatric patients less than five years old require additional work. For the more complex venous access insertion procedures in the premature infant (body weight less than 4 kg), a –63 modifier should be assigned with the appropriate CVA (30000 series) code. A –63 is not to be reported with radiology 70000 series code.

For additional information on the central venous access device codes, please refer to the November/December 2003 edition of the ACR Radiology Coding Source™ online or the March 2004 edition of the Journal of the American College of Radiology.