Radiology Coding - American Health Information …

1 Copyright 2007 American Health Information management association . All rights reserved. Radiology Coding Audio Seminar/Webinar July 17, 2007 Practical Tools for Seminar Learning Disclaimer AHIMA 2007 Audio Seminar Series i The American Health Information management association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.

2 CPT five digit codes, nomenclature, and other data are copyright 2006 American Medical association . All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. As a provider of continuing education, the American Health Information management association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: (1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation; (2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and (3) if the presentation will include discussion of investigational or unlabeled uses of a product.

3 The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with Information from which they may make their own judgments. Faculty AHIMA 2007 Audio Seminar Series iiStacie L. Buck, RHIA, CCS-P, LHRM, RCC Ms. Buck has served in several different roles during her 14-year career in Health Information management including as a medical records coordinator, medical coder, a revenue analyst, an internal auditor, corporate compliance officer, and consultant. She is currently Vice President and Managing Partner of Southeast Radiology management in Stuart, Florida. She is on the editorial advisory board for the HCPro newsletters Mammography Regulation Report, Radiology Administrator s Compliance Insider, Health Care Auditing Strategies and she is a frequent contributor to Strategies for Health Care Compliance and to Compliance Monitor Q & A s Ask the Expert.

4 In addition, she is the author of the recently released Radiology Technologist s Coding Compliance Handbook and is a Contributing Editor for The Radiology Manager s Handbook: Tools & Best Practices for Business Success. Stacie also is an audioconference presenter for HCPro, the Coding Institute and the American Health Information management association (AHIMA). An adjunct instructor and advisory board member for the Health Information management program at Indian River Community College in Florida, Stacie also serves in the AHIMA Mentoring program. Recently she was the recipient of several awards including the 2005 AHIMA Rising Star Award, FHIMA Outstanding Professional Award & FHIMA Literary Award. Stacie is a current member of the American Health Information management association (AHIMA), the Florida Health Information management association (FHIMA) and the Suncoast Health Information management association (SHIMA). She serves on the AHIMA Physician Practice Council and is President of the Florida Health Information management association .

5 Stacie graduated Magna Cum Laude from Florida International University with a Bachelor of Science degree in Health Information management after earning an Associate of Arts degree in Business Administration. Table of Contents AHIMA 2007 Audio Seminar Series Disclaimer ..i Faculty ..ii Objectives .. 1 CPT 1 Supervision and Interpretation .. 2 CMS 3 Contrast Materials .. 3 Coding and Documentation .. 4 Report Documentation Screening 5 Diagnostic 6 Diagnostic vs. Screening 6 High Risk V codes .. 7 3D Rendering .. 7 PET and CT Coding Questions ..11 US Documentation Guidelines CPT ..14 Retroperitoneum ..16 Abdominal and Pelvic vs. Transabdominal ..18 Transabdominal vs Transvaginal ..18 OB vs. OB vs. OB OB Ultrasound Guidance ..21 US w/US Guidance ..22 US Guidance Vascular Access ..23 Duplex Scans ..23 Coding Signs and Symptoms or a No Reason for Code Signs/Symptoms ..27 Coding FAQs Pecking Order for Dx Common Radiology Modifiers -26 and TC.

6 29 -50 and -52 ..30 -53 ..31 -50 ..32 -76 and -77 ..33 -GG, -GA, -GY and CZ ..34 Florida Whistleblower Case ..36 Why the Confusion ..37 42 CFR ..38 Common Table of Contents AHIMA 2007 Audio Seminar Series Test Orders in the Hospital ACR Guidelines for Communication ..43 References and Resources ..44 Audience Questions Appendix ..48 CE Certificate Instructions Radiology Coding AHIMA 2007 Audio Seminar Series 1 CPT Codes Copyright 2006 by AMA. All Rights Reserved Notes/Comments/QuestionsObjectives Review ICD-9-CM Diagnostic and CPT Coding guidelines for Radiology services including X-Ray, Ultrasound, CT, MRI, PET, Nuclear Medicine, and Mammography. Discuss modifier usage, contrast media, supervision and interpretation. Review documentation requirements for accurate code assignment and for Medical CPT Guidelines CPT-Specific Guidelines Carefully review the guidelines at the beginning of each section in CPT Know and adhere to the subsection - and code-specific guidelines and documentation requirements.

7 Utilize CPT Assistantreferences when available/applicable. Clinical Examples in Radiology AMA/ACR2 Radiology Coding AHIMA 2007 Audio Seminar Series 2 CPT Codes Copyright 2006 by AMA. All Rights Reserved Notes/Comments/QuestionsCPT Guidelines Written report, signed by the interpreting physician should be considered an integral part of a radiologic procedure or interpretation. When a procedure is performed by 2 physicians, the radiologic portion of the procedure is designated as RS&I If physician performs both procedure and RS&I use surgical codes in addition. 3 Supervision and Interpretation Radiological supervisionand interpretation(RS&I) codes require just that both supervision and interpretation by the radiologist If either supervision or interpretation is not performed, append a modifier -52 to the RS&I code 4 Radiology Coding AHIMA 2007 Audio Seminar Series 3 CPT Codes Copyright 2006 by AMA. All Rights Reserved Notes/Comments/QuestionsCMS Guidelines NCD and LCD Although the Medicare Manuals may not specifically address elements required for a report, don t forget there may be specific NCD or LCD documentation requirements!

8 Locate and review all applicable coverage determinations. 5 Contrast Materials With contrast" refers to contrast administered: Intravascularly Intra-articularly Intrathecally6 Radiology Coding AHIMA 2007 Audio Seminar Series 4 CPT Codes Copyright 2006 by AMA. All Rights Reserved Notes/Comments/QuestionsContrast Materials Injection of IV contrast is part of the "with contrast" - CT, CTA, MRI, and MRA procedures. For intra-articular injection, use the appropriate joint injection code. For spine examinations "with contrast" -intrathecal or intravascular injection. For intrathecal injection, use also 61055 or 62284. Oral and/or rectal contrast administration alone does not qualify as a study "with contrast."7 Contrast Coding and Documentation Route of administration Type Concentration Amount Injecting the material is bundled , however the appropriate HCPCS code should be assigned for the Radiology Coding AHIMA 2007 Audio Seminar Series 5 CPT Codes Copyright 2006 by AMA.

9 All Rights Reserved Notes/Comments/QuestionsReport Documentation Number and types of views Amount, type and route for contrast Separate interpretations for each exam performed Don t forget to check your LCDs! Medical necessity Documentation requirements9 Screening Mammography 77057 Performed on asymptomatic females that have not manifested any clinical signs, symptoms, or physical findings of breast cancer. CC & MLO views are obtained of each breast. 10 Radiology Coding AHIMA 2007 Audio Seminar Series 6 CPT Codes Copyright 2006 by AMA. All Rights Reserved Notes/Comments/QuestionsDiagnostic Mammography 77055 & 77056 Also called problem-solving mammography or consultative mammography Performed because there is a reasonable suspicion that an abnormality may exist Clinical signs, symptoms, or physical findings suggestive of breast cancer An abnormal or questionable screening mammogram A personal history of breast cancer A personal history of biopsy-proven benign breast disease.

10 A woman is asymptomatic, but based on her history and other factors the physician feels diagnostic is appropriate Additional views performed11 Diagnostic vs. Screening Mammogram Implants ACR: Asymptomatic, diagnostic; Symptomatic,diagnostic CMS: Asymptomatic, screening; Symptomatic,diagnostic History of biopsy-proven benign disease ACR: Diagnostic CMS: Diagnostic or screening as determined byreferring physician History of mastectomy ACR: Diagnostic (life-long) CMS: May revert to a screening as determined bythe referring physicianACR Coding Source, May/June 200612 Radiology Coding AHIMA 2007 Audio Seminar Series 7 CPT Codes Copyright 2006 by AMA. All Rights Reserved Notes/Comments/Questions vs. What constitutes high risk ? CMS considers the following patients to be high risk: Has a personal history of breast cancer ( ) Has family history of breast cancer ( ) Mother Sister Daughter Had her first baby after age 30 ( ) Has never had a baby ( ) Assign as primary, above as secondary13 3D Rendering -76376/76377 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation14 Radiology Coding AHIMA 2007 Audio Seminar Series 8 CPT Codes Copyright 2006 by AMA.