ACR Radiology Coding Source™ Sept-Oct 2006

Look for pertinent changes in the CPT® 2007 code book that will affect radiology practices and require revision to your computer systems and charge sheets. Significant among the changes is the relocation of a number of older codes to more specific sections within the CPT code book, eg, relocation of mammography and most guidance codes to the 77000 series section.

Among the new codes for 2007 are functional MRI, nuchal translucency measurements, percutaneous radiofrequency ablation of pulmonary tumor(s), a unique all-inclusive code to describe uterine fibroid embolization, placement of fiducial markers in prostate, stereotactic body radiation therapy and stereotactic radiosurgery, and revision to the nuclear medicine genitourinary code section. As well, a number of additions and deletions will be made to the Category III (tracking) CPT code section.

A number of codes have been deleted due to the renumbering of some of the codes as described above. Provided in this publication, for your convenience, is a table that crosswalks the deleted codes to the newly relocated codes, as well as a listing of the newly established 2007 radiology codes.

It is important that your practice has all billing systems updated and the new 2007 codes available for use when these codes become valid on January 1, 2007. 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. Providers, , carriers, and intermediaries no longer have a 90-day grace period to implement new code sets.

Renumbering and Relocation of Numerous Radiology Codes

The relocation of a number of CPT codes within the 2007 CPT codebook is part of an AMA organizational restructuring (CPT 5 Data Model Project)* to facilitate computer processing and interoperability with various computer systems. Codes which were previously listed in the "Other" section have been relocated to more descriptive sections. This relocation will include a host of codes with which many are familiar: mammography codes (76082, 76083, 76086, 76088, 76090, 76091, 76092, 76093, 76094, 76095, 76096); most guidance codes (75998, 76003, 76005, 76006, 76355, 76360, 76362, 76370,76393, 76394); bone studies(76020, 76040, 76061, 76062, 76065, 76066, 76070, 76071, 76075, 76076, 76077 76078, 76400); and vertebroplasty codes (76012, 76013). Most of the old codes will be deleted and replaced with new codes relocated to the beginning section of the 77000 series section of the CPT codebook prior to the radiation oncology codes, while a few are being relocated to other more appropriate sections. Because of the number of radiology codes needed to be relocated, the beginning of the 77000 series of codes was the only choice.

*To read more about the CPT 5 Data Model project, go to the AMA Web site.

Diagnostic Radiology

Functional MRI

Functional MRI is distinct from the currently established magnetic resonance imaging codes. Those codes are used to evaluate the structure and pathology only of specific anatomic sites and neighboring anatomy, not function. Functional MRI imaging codes (70554, 70555) were created to describe the MRI imaging performed while the patient is active to evaluate human cognitive functions, such as motor skills, vision, language, and memory. When the imaging is provided without neurofunctional testing by a physician or psychologist, only code 70554 is reported. However, when the imaging is performed in conjunction with neurofunctional testing performed by a physician or psychologist, the imaging is reportd by code 70555. Code 96020 (Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and report) is reported by the physician or psychologist who administers the test. The physician or psychologist is responsible forselection and administration of testing of language, memory, cognition, movement, sensation, and other neurological functions when conducted with functional neuroimaging, monitoring of performance of this testing, and determination of validity of neurofunctional testing relative to separately interpreted functional magnetic resonance images.¹

In most cases, functional MRI is performed in the setting of a known intracranial abnormality. Reporting a traditional diagnostic MRI at the same setting would be unusual.² (JACR, New Year, New Codes…And All New Confusion) If MRI brain imaging is performed on the same day as a functional MRI of the brain study, a separate order would be necessary and a modifier (eg, 59) used to designate a separate and distinct service was performed in addition to the functional MRI study.

MRI Orbit, Face, and/or Neck (70540, 70542, 70543) Revision

The MRI Orbit, Face, and Neck codes (70540, 70542, 70543) currently specify "and" in the descriptor. This has caused some confusion among payers who incorrectly interpreted the description to mean that all three separate sites had to be evaluated in order to use this code. Therefore, these codes were revised to state MRI orbit, face, "and/or" neck. This revision makes it clear that this code should be reported only once per imaging session whether one or all three distinct sites are evaluated.

Ultrasound

Nuchal Translucency Measurements

Nuchal translucency measurement, a method for detecting fetal chromosomal abnormalities (eg, Downs syndrome) in the first trimester, will be described by code 76813 for evaluation of a single or first gestation, and code +76814 for each additional gestation evaluated. The ACR commented during the CPT Editorial Panel’s discussion of this new code that it felt the limited obstetrical code 76815 would appropriately describe this procedure. However, the CPT Editorial Panel felt a separate code was warranted and established Category I CPT codes for 2007. Because the editorial panel feels that a nuchal translucency measurement should be described by a separate and distinct code (which means that currently it is not accurately described by an existing code), the ACR recommends the use of the unlisted procedure code 76999 until the new codes are released for use in 2007.

If a nuchal translucency measurement is requested in the first trimester in addition to a complete ultrasound (76801, 76802) or a limited ultrasound (76815), it would be appropriate to code for both the nuchal translucency study (76813 or 76814) and the first trimester or limited ultrasound procedure. As noted in the CPT code application, the nuchal translucency measurement codes are used to describe a more detailed evaluation of specific embryonic structures than is required by either code 76801, 76802 or 76815.

Ultrasound of Transplanted Kidney

76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

Code 76778 (Ultrasound, transplanted kidney, B-scan and/or real time with image documentation, with or without duplex Doppler study) will be deleted in 2007. A new code (76776) has been created to describe an ultrasound of a transplanted kidney with duplex Doppler. The deletion of the current code and creation of a new code were necessary because of a rank order anomaly that currently exists in CPT for code 76778, which is grossly undervalued. There is considerably more work involved in a transplanted kidney study with the addition of Doppler. It was felt that the best solution was to delete code 76778, create a new code to describe a "with" duplex Doppler study of a transplanted kidney, and recommend the reporting of a without duplex Doppler study with the limited retroperitoneal ultrasound code 76775.

"B-Scan" Terminology Elimination

The "B-scan" terminology used in the descriptors of the ultrasound codes will be eliminated (except for the ophthamological codes) in order to more accurately describe the way procedures are performed today, ie, in realtime. Since this is purely an editorial change, these revisions were not forwarded to the Relative (Value) Update Committee (RUC) for revaluation.

Interventional Radiology

Percutaneous Radiofrequency Ablation of Pulmonary Tumor(s)

CPT code 32998 has been added to report percutaneous radiofrequency ablation (RFA) of one or more pulmonary tumors. Currently, an unlisted procedure code is being used to describe this service. Beginning in 2007, the image guidance and monitoring associated with this procedure and other visceral (organ) RFA procedures should be reported separately by codes 77013 (replaces 76362 for CT), 77022 (replaces 76394 for MR), or 76940 (ultrasound) depending on the type of guidance provided. In addition to 32998, codes currently exist to describe RFA of bone (20982), liver (47382), and renal (50592). The addition of 32998 expands the use of the radiofrequency ablation technology used in tumor reduction or eradication to a new anatomic site not described currently in CPT.

Note that the RFA of bone tumor(s) code includes the CT guidance within the code descriptor because CT guidance is the only guidance being used with RFA of bone tumors. However, if an RFA of a bone tumor(s) using fluoroscopy is performed the ACR recommends that the unlisted musculoskeletal procedure code (20999) and fluoroscopic guidance (76003) be reported. The rationale is that 20982 (Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance) was described and valued as being done with CT guidance and, therefore, is accurate only for bone RFA with CT guidance. If a significant use of fluoroscopic or other guidance for this procedure develops (which is felt to be unlikely), then additional codes would have to be created.

Uterine Fibroid Embolization

Look for a new all-inclusive code to describe uterine fibroid embolization (UFE). Because of a trend by payers to create HCPCS Level II "S" codes to describe UFE, and with an increasing number of providers not being paid for the service, the ACR and Society of Interventional Radiology felt a separate and distinct code for UFE was needed. Creation of an all-inclusive code was possible since UFE has reached a point in clinical practice where it is being performed using a relatively uniform technique by many physicians. The creation of this new code for UFE leaves the existing embolization codes (37204, 75894) to accurately describe the work of embolization for the many other indications where this service applies. As noted in the descriptor, code 37210 includes vascular access, vessel selection, embolization, and all imaging, i.e., radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure.

Fibroadenoma Cryoablation

19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma

Category III code 0120T will be deleted and replaced by 19105 to describe cryosurgical ablation of fibroadenoma. The use of ultrasound guidance has been included in this code and should not be reported separately. It should be noted that the CPT Editorial Panel has begun to include the use of guidance in the procedure code when the procedure and guidance is typically performed by the same physician. As specified in the descriptor, this code should be reported for each fibroadenoma that is cryosurgically ablated.

Percutaneous Intradiscal Electrothermal Annuloplasty

Category III codes 0062T and 0063T have been converted to Category I codes 22526 and 22527, respectively, to describe reporting a unilateral or bilateral percutaneous intradiscal electrothermal annuloplasty procedure (22526) and one or more additional levels (22527). Note that fluoroscopic guidance is included in this procedure, therefore, it is not appropriate to report fluoroscopy in addition to these procedures. Intradiscal electrothermal annuloplasty is used in the treatment of back pain. A thermal change in annular tissue is created by placing a needle or catheter, which is subsequently heated, into a disk.

Radiation Oncology

Look for four new codes to be established in the Radiation Oncology section in 2007 to describe stereotactic body radiation therapy and stereotactic radiosurgery.

Stereotactic Radiosurgery (SRS)

Two new codes have been created to describe stereotactic radiosurgery (SRS) (also known as stereotactic radiotherapy) treatment using a multisource Cobalt 60 based delivery (77371) and linear accelerator based (77372). Prior to establishing these codes, Medicare used HCPCS codes G0243 and G0173 to describe these procedures

Stereotactic Body Radiation Therapy (SBRT) Codes Converted to Category I Status

Category III code 0082T (Stereotactic body radiation therapy, treatment delivery, one or more treatment areas, per day) and 0083T (Stereotactic body radiation therapy, treatment management, per day) have been converted to Category I codes (77373 and 77435) as the process of care has matured and data supports its more widespread use.

Placement of Interstitial Devices (eg, Fiducial Markers)

55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate

Although codes exist for preop placement of localization wire and a metallic localization clip in the breast, there currently is no code to describe the placement of a fiducial marker in the prostate. Placement of this interstitial device currently is being overlooked or reported with the unlisted male genitourinary procedure unlisted code 55899. Code 55876 will be available in 2007 to describe the placement of an interstitial device in the prostate to ensure the accurate treatment of the target and to spare normal surrounding tissue. Devices, such as fiducial markers, are a safe and appropriate way to verify and correct the position of the target organ during subsequent image-guided external beam radiotherapy.

Nuclear Medicine

Genitourinary Code Section Revisions

The Society of Nuclear Medicine and the ACR submitted a request to revise the nuclear medicine genitourinary code descriptors (78700, 78701, 78707, 78708, 78709, 78710) to provide better distinction between the codes and prevent misuse. With this revision, three codes will be deleted: 78715 – an obsolete kidney imaging procedure; 78704 - which is more appropriately reported with the renal vascular and flow function codes 78707-78709; and 78760 (testicular imaging) since testicular imaging is always done with vascular flow (reported by 78761). In addition to the above, the urinary bladder residual study code (78730) will be changed to an add-on code that may be reported in conjunction with a ureteral reflux study (78740).

Category III Codes

Deletions

Deleted Category III codes include: percutaneous intradiscal electrothermal annuloplasty codes 0062T and 0063T (replaced by codes 22526 22527); stereotactic body radiation therapy codes 0082T and 0083T (replaced by 77373 and 77345); cryosurgical ablation of fibroadenoma code 0120T (replaced by 19105); and computer-aided detection with chest x-ray code 0152T (replaced by +0174T and 0175T).

Additions

Catetory III code 0159T has been created to describe computer-aided detection performed in conjunction with a breast MRI study. This add-on code is to be reported in addition to either the unilateral or bilateral breast codes, 77058 (formerly 76093) or 77059 (formerly 76094). Because this code includes all post-processing imaging, 3D reconstructions should not be reported separately. This code was approved by the CPT Editorial Panel in January 2006 and has been available for use since July 2006.

The add-on code +0152T will be deleted and replaced by two distinct codes to differentiate between CAD performed concurrent with a chest x-ray (add-on code +0174T) and CAD performed separately from the primary chest x-ray interpretation (0175T). Two distinct codes were needed since it was found that chest CAD interpretations were being performed separately from the main chest x-ray procedure. Because an add-on code must be reported by the same physician who interprets the primary interpretation, this revision was necessary. Codes +0174T and 0175T are available for use as of January 1, 2007.

Category III codes approved by the panel in July of each year are issued too late for inclusion in the following year's CPT code book. Therefore, for a listing of new Category III codes approved but not included in the CPT 2007 code book, go to the AMA Web site .

Information on CPT® Category III Codes

Category III codes are used primarily for tracking new procedures and are NOT referred to the AMA Relative Value Update Committee for valuation. However, they are carrier priced if the service is covered.

Updates are posted biannually (January and July) and are effective six months after posting. This delay provides time for providers/payers to update systems. These codes are maintained until they meet Category I code requirements or they are archived after five years unless a further need is demonstrated to maintain the Category III code status. For more detailed information on CPT® Category I, II and III codes, go to the AMA web site .

For a complete listing of CPT® Category I, II, and III codes for 2007, please refer to the CPT 2007 code book.

¹AMA's CPT Changes 2007: An Insider's View.

²(JACR, New Year, New Codes…And All New Confusion)