ACR Radiology Coding Source™ Sept-Oct 2004

Feature

Effective as of January 1, 2005, radiology practices must use the new CPT® codes (Pub 100-04 Medicare Claims Processing, Transmittal 89) to report procedures/services rendered and as of October 1, 2004 the new ICD-9-CM codes (Pub.100-04 Medicare Claims Processing, Transmittal 95) to report diagnoses. The Centers for Medicare and Medicaid Services (CMS) notified its Medicare Carriers and Intermediaries that the Health Insurance Portability and Accountability Act (HIPAA) transaction and code set rules require the use of the medical code set that is valid at the time the service is provided. Carriers and intermediaries will no longer be given the 90-day grace period to implement new codes.

To assist in preparation for the new CPT® coding year beginning January 1, 2005, the ACR offers the following highlights of major code changes that will affect radiology practices for 2005.

Nuclear Medicine

PET and PET/CT

The Positron Emission Tomography code 78810 for non-brain, noncardiac PET studies was deleted and 6 new codes created to describe PET (78811-78813) and PET/computed tomography (CT) (78814-78816) studies.

Three new codes were developed to more accurately describe the work involved in the various PET procedures. A limited area PET study, such as of the chest or head/neck, is identified by 78811. A PET study from the skull base to mid-thigh level is identified by code 78812 and a whole body PET study is reported by code 78813.

Procedure codes to describe PET performed with concurrently acquired CT for attenuation correction and anatomical localization procedures will be identified by three new codes structured in the same way as the PET studies, i.e., 78814 for a limited area PET/CT, 78815for a PET/CT study from the skull base to mid-thigh level, and 78816 for a whole body PET/CT study.

A cross-reference has been added to the CPT® book to note that a CT study performed for other than attenuation correction and anatomical localization should be reported separately using the appropriate site-specific CT code with modifier -59 to denote this as a separate and distinct procedure. It is noted also in a parenthetical following codes 78811-78816 that the PET and PET/CT codes should be reported only once per imaging session.

Whether Medicare will use these newly created CPT® codes in place of HCPCS Level II "G" codes to describe the PET and PET/CT studies is pending. Check the ACR Web site in November for an update on this issue.

No changes have been made to the PET brain (78608, 78609) or PET myocardial imaging (78491, 78492) codes.

Therapeutic Procedure Codes

A major change in the reporting of nuclear medicine therapeutic procedures will take effect in 2005. The 79000 series CPT® therapeutic codes were revised to differentiate the radiopharmaceutical therapy codes by route of administration (i.e., intravascular, intra-articular, intracavitary, etc.) versus disease-specific codes (e.g., radiopharmaceutical therapy for hyperthyroidism or ablation of gland for thyroid carcinoma). While some changes were editorial only, such as intracavitary (79200), interstitial radioactive colloid (79300), and intra-articular (79440), other disease-specific codes were deleted (79000, 79001, 79020, 79030, 79035, 79100, 79400, 79420) and new codes were created to differentiate by oral (79005), intravenous (79101), and intra-arterial (79445) administrations. A number of cross-references under the therapeutic codes have been added, as well, for clarification.

Clarification is provided at the beginning of the Nuclear Medicine therapeutic code section of CPT® 2005 to note that for intra-arterial, intra-cavitary, and intra-articular administration, it is appropriate to report injection and/or procedure codes, imaging guidance and radiological supervision and interpretation codes separately when appropriate. However, it is noted that the mode of administration is inclusive in the oral and intravenous therapeutic codes.

CPT® Radiopharmaceutical Supply Codes Deleted in 2005

It is important to note the deletion of the CPT® radiopharmaceutical supply codes 78990 (diagnostic) and 79900 (therapeutic) in 2005. Reporting for these supplies will be by HCPCS level II codes. If a radiopharmaceutical-specific HCPCS level II code is not available, radiology practices should use one of the not otherwise classified HCPCS codes (e.g., A4641 for a diagnostic radiopharmaceutical not otherwise classified). See CMS and other third party payer guidelines regarding the reporting of these radiopharmaceutical supplies. An introductory note has been added to the NM section of CPT 2005 stating that these diagnostic and therapeutic radiopharmaceucticals supplied by the physician are to be reported separately.

Other NM Changes

Note additional editorial changes to the descriptors for urea breath test (78267) to include the term isotopic, SPECT myocardial perfusion imaging (78464, 78465) to denote these studies include attenuation correction, and the unlisted procedure (79999) to be consistent with the other radiopharmaceutical therapy descriptors.

Diagnostic Radiology

Ultrasound

Guidelines Updated

Detailed guidelines developed by a CPT® Editorial Panel ultrasound workgroup are provided at the beginning of the Diagnostic Ultrasound Subsection of Radiology in the CPT® 2005 book. Requirements for the reporting of ultrasound procedures are listed and include: permanently recorded image documentation with measurements (when measurements are indicated) and a final written report. Ultrasound guidance procedures also require permanently recorded images and documentation of the localization process in a separate report or within the report of the procedure. A description of all elements included in a complete study must be given. If a required element cannot be visualized, the reason for non-visualization (e.g., obscured by bowel gas) must be given or the limited study code must be reported. A listing of elements included in a complete study are provided for the reporting of abdominal, retroperitoneal, and pelvic ultrasound studies. Another important notation provided states that non-invasive vascular diagnostic Doppler studies (93875-93990) are separately reportable when provided for other than color flow used only for anatomic structure identification.

Doppler Velocimetry

Two new fetal Doppler velocimetry codes of the umbilical artery (76820) and middle cerebral artery (76821) have been added, and the general term "cardiovascular system" has been deleted from the existing fetal Doppler echocardiography code (76827) to clearly differentiate between these fetal Doppler studies.

Category III Codes Describe CT Colonography/MR-Guided Focused Ultrasound Category

Four new category III codes have been developed to describe CT colonography (CTC) and MR-guided focused ultrasound ablation studies, which are not yet ready to be assigned a category I code. These Category III codes, which became effective in July of 2004, will be listed in the CPT® 2005 book.

Two codes were established to describe and to differentiate between CTC (also referred to as virtual colonoscopy) performed for screening (0066T) and for diagnostic (0067T) purposes. As noted in the cross-reference following these codes, you should not use these codes in conjunction with the CT abdomen (74150-74170), CT pelvis (72192-72194) or reconstruction (76375) codes.

Two codes were established to describe MR-guided focused ultrasound ablation of uterine leiomyomata differentiated by total leiomyomata volume less than 200 cc of tissue (0071T) and total leiomyomata volume greater or equal to 200 cc of tissue (0072T) . The continuous MR imaging used for guidance and monitoring, and catheterization have been valued into this procedure, therefore, neither 76394 (MR guidance) nor 51702 (insertion of temporary indwelling bladder catheter) should be reported in conjunction with these codes.

Vertebral Fracture Assessment

Look for a new code (76077) to describe vertebral fracture assessment (VFA) by dual energy x-ray absorptiometry (DXA). VFA uses AP and lateral views of the thoracic and lumbar spine obtained on DXA equipment to determine a patient’s increased risk for future fractures and if pharmacological intervention is required. Comparison of the VFA views is made with previous radiographic or VFA images. VFA images are typically acquired concurrent with a DXA study, in which case both the DXA and VFA studies are separately reported. If a central DXA study has been performed elsewhere, it is appropriate to report only the VFA study code.

Breast Surgery Introductory Text

See the new introductory text which has been added to the beginning of the Breast Surgerysection of CPT® 2005. Guidelines are provided on the use of the appropriate percutaneous and open surgical procedure codes.

Interventional Radiology

Diagnostic Angiogram/Venogram RS&I and Interventional Therapeutic Vascular RS&I Guidelines

Detailed guidelines are provided to clarify the circumstances under which a radiology practice may report both a diagnostic angiogram/venogram radiological supervision and interpretation (RS&I) study in conjunction with an interventional therapeutic vascular RS&I study. These guidelines were recommended by the ACR and Society of Interventional Radiology (SIR) in order to avert the implementation of CCI edits by CMS; however, CMS implemented edits in V10.3. See New CCI Edits Impact Interventional Radiology Coding in the CCI edit section for further discussion of this issue.

Endovenous Thermal Ablation

Four new codes were established to describe endovenous ablation therapy of incompetent veins (varicose veins). Two codes describe percutaneous radiofrequency ablation (36475 for 1st vein, +36476 for two or more veins) and two codes describe percutaneous laser ablation (36478 for 1st vein, +36479 for two or more veins). These codes include the placement of the needle or catheter and all imaging guidance and monitoring. Duplex scanning to ensure proper occlusion of the vein is also included and should not be reported separately. However, it is appropriate to code a diagnostic duplex scan (93970, 93971) of the extremity veins if medically necessary and performed on the same day.

Endovascular Repair of Abdominal Aortic Aneurysm (AAA)

Another Category I code was added to the endovascular repair of abdominal aortic aneurysm (AAA) codes. Code 34803 was created to differentiate this repair of infrarenal AAA or dissection using a modular bifurcated prosthesis (two docking limbs) from the other endovascular repair codes. The Category III code 0001T, which previously described this procedure, was deleted.

Fenestrated Aortic Endograft Placement

Two new Category III codes (0078T, +0079T) to describe placement of a fenestrated aortic endograft to treat abdominal aortic aneurysms involving the visceral arteries and two associated Category III radiological supervision and interpretation codes (0080T, +0081T) will be implemented on January 1, 2005. Reference the CPT 2005 book for a listing of the services which should not be reported in conjunction with these procedures when performed on the same day by the same physician. Note that the Category I guidelines for endovascular abdominal aneurysm repair, located in the Cardiovascular System/Surgery section (prior to 34800-34826), are applicable to this set of Category III codes as well.

Carotid Stenting

Two new Category I codes were created to describe cervical carotid artery stenting, which are differentiated by those procedures performed with distal embolic protection (37215) and those procedures performed without distal embolic protection (37216). When codes 37215 and 37216 confirm the need for carotid stenting, these codes are all inclusive, i.e., includes all diagnostic imaging for ipsilateral (same side) cervical and carotid arteriogram and all related RS&I procedures. However, it is appropriate to code for carotid catheterization and imaging if carotid stenting is not performed.

Also, effective January 1, 2005, the Category III codes 005-007T that describe extracranial cerebrovascular artery stents will be deleted and two new Category III codes implemented that specifically describe extracranial vertebral or intrathoracic carotid artery stenting (0075Tfor the initial vessel, and 0076T for each additional vessel).

An editorial change also was made in the intravascular stent placement codes 37205 (initial vessel), 37206 (each additional vessel) and associated RS&I code 75960 to note that these codes refer to vessels other than the coronary, carotid and vertebral vessels.

Insertion of Indwelling Tunneled Pleural Catheter with Cuff

A new code (32019) has been added to report the insertion and management of a tunneled pleural catheter into the pleural space for drainage and management of pleural effusions. The work involved in this procedure (multiple incisions and subcutaneous tunneling with peri-operative management) is more extensive than that described by code 32020 (tube thoracostomy) which only requires a single chest wall puncture.¹ When imaging guidance is used, it is appropriate to report the radiology supervision and interpretation code 75989 to describe this guidance.

Radiation Oncology

A number of Category III codes were developed to describe new technology procedures being used within radiation oncology.

Compensator-Based Beam Modulation Treatment Delivery

Code 0073T, which became effective in July 2004, was created to describe compensator-based beam modulation treatment delivery per treatment session. The compensator beam modulation technique is clinically different than what was approved for IMRT and described by code 77418 (Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams…). For the delivery of the compensator beam mode of radiotherapy, another form of beam modulation is used instead of the multileaf collimation used in IMRT. Therefore, there is a difference in technique and in the level of practice expense incurred by the CBRT approach. As noted in the cross-reference following this code, do not report this code in conjunction with the other radiation treatment delivery codes (77401-77416, or 77418).

Stereotactic Body Radiation Therapy

Stereotactic body radiation therapy (SBRT) treatment delivery (0082T) and treatment management (0083T) codes will become effective as of January 1, 2005. Initially, stereotactic radiation therapy was used only to treat intracranial lesions. However, more recent technological advances have allowed this technique to be applied to many other parts of the body; in that case, it is referred to as SBRT.² As noted in the cross-references following these codes, do not report these codes in conjunction with the other radiation treatment delivery (77401-77416, 77418) or treatment management (77427-77432) codes.

Placement of Radiotherapy Afterloading Catheters for Breast Brachytherapy

Three new category I codes (19296, 19297, and 19298) will be implemented in 2005 to describe catheter placement and removal for interstitial radioelement application in the breast following a partial mastectomy. These codes are differentiated by type of catheter (balloon vs brachytherapy – multiple tube and button type). The balloon type catheters are further differentiated by when the procedure is performed. As noted in the descriptor, code 19296 is reported when the date of service is separate from the partial mastectomy, and 19297 is reported for services that are performed concurrent with partial mastectomy. Code 19298 is reported whether the catheters are placed "at the time of" or "subsequent to" the partial mastectomy.

The isodose plan (77326-77328) and the remote afterloading brachytherapy administration (77781-77784) are reported separately for these procedures.

Elimination of CPT® Code 79900

An important change that will affect radiation oncology practices is the elimination of the radiopharmaceutical supply code 79900 as of January 1, 2005. HCPCS level II codes will be required to report supply and device items. The ACR is working to activate a new "Q" code for brachytherapy seeds. See the Nuclear Medicine section of this article for additional information on the elimination of code 79900.

Other

Conscious sedation

The CPT® 2005 book has added Appendix G to provide a listing of CPT® codes that identify those procedures that include conscious sedation as a typical component. A "bulls-eye" symbol also has been placed next to the procedure codes in the CPT® book to identify these procedures. The physician performing a procedure for which conscious sedation is inherent would not code separately for the conscious sedation.

References

As noted previously, be sure you are compliant by using valid CPT®, HCPCS level II and ICD-9-CM codes as of their effective dates. You may obtain the latest in coding updates by referencing the following sources:

CPT® 2005 Book (New codes effective January 1, 2005) 
AMA Phone: (800) 621-8335

Category III Codes (Updates posted twice yearly in January and July with implementation dates noted)

HCPCS Web site for HCPCS Level II codes (Quarterly updates)

ICD-9-CM Diagnosis Codes (New codes effective October 1, 2004)

¹CPT® 2005 Changes: An Insider's View, AMA.
²ASTRO/ACR Guide to Radiation Oncology Coding 2005, Chapter 14, p.77.