# Digital Motion X-ray (DMX)



## pattytpa

What would be the appropriate code for this? 76120 or is this an 76499?


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## mmiscoe

*Dmx*

Your question is a common one that requires some clarification before it can be answered.  First it is important to understand that DMX is a diagnostic fluoroscopic device.  Second, your question offers a choice between two inaccurate codes as explained below. I have evaluated this issue extensively and have testified as an expert on this issue numerous times.  This is an interesting case for code analysis since it so aptly demonstrates how coders can be foiled by seemingly persuasive opinions.  Only by applying an objective analytical approach is the proper answer determined.

Much of the confusion relating to this service is in part because the trade name of the device is not illustrative of the technology involved, and second because of pressure placed on the AMA CPT IS division which has resulted in contradictory opinions to similar questions.

Resolution of the question "How should the fluoroscopic service provided by the DMX TM device be coded?" requires that we start with fundamental coding criteria.  As we will see, CPT 76496 is the only correct code for reporting diagnostic fluoroscopy using the DMX videofluoroscopic device. The rationale supporting this conclusion is as follows:

1. The Health Insurance Portability and Accountability Act of 1996 contained a statutory framework known as the Transaction and Codeset standards. 42 U.S.C. § 1320d-4(a)(1)(B).  This statutory rule requires all covered entities including most healthcare providers and all carriers to use the codes and descriptions published in CPT-4, HCPCS Level II and ICD-9-CM as the exclusive coding rules. The interesting aspect of this rule is that only the codes and descriptions are included. Any additional interpretive guidance or usage rules must be established by statute or contract. Clarifications in CPT or the CPT Assistant or other publications are not part of the mandated codeset. 45 C.F.R. § 162.1002(e)(1).  As such, unless incorporated by statute, regulation or contract into the reimbursement scheme as a criteria of payment, this information is at best persuasive (as opposed to controlling)

2. Based on the HIPAA mandated Transaction and Codeset rules, as well as the “Instructions for use of CPT” contained within the CPT-4 Manual itself, which are persuasive on this point, there may not be more than one HCPCS/CPT code to describe a service.

3. References such as the AMA's CPT Assistant are often cited and in some cases persuasive but are not controlling unless expressly incorporated as a controlling reference by statute/contract.  While many carrier medical policies/contracts or statutory reimbursement schemes expressly reference AMA CPT-4, few incorporate the opinions contained in the CPT Assistant as controlling criteria.  As a result, these references are at best persuasive.  In this case, as shown in the analysis below, reliance on the CPT Assistant is improper as the conclusions rendered are inaccurate and therefore irrelevant. 

4. Where the CPT coding conventions contained within the CPT manual are applied, as is demonstrated in the discussion portion of this analysis below, CPT 76496 is the only code that correctly describes the Fluoroscopic/Digital Motion X-Ray procedure performed.

*DISCUSSION*
Where CPT coding conventions contained within the body of the CPT-4 Coding Manual are applied, we can not only determine the correct code for any service, including diagnostic fluoroscopy performed using the DMX device, we can also identify where the opinions expressed in the CPT Assistant on this issue diverge from the standards mandated in the CPT manual. 

1. The September 2000 publication of the AMA CPT Assistant that equated videofluoroscopy to videofluorography/cineradiography is well known; however, subsequent changes to CPT have invalidated the AMA position expressed in the September 2000 edition of the CPT Assistant.  Moreover, the validity of this position (that videofluorography and videofluoroscopy were the same) is easily challenged.  Even in 2000, CPT defined a number of services using the term “videofluoroscopy” instead of the videoflourographic label that the September 2000 CPT Assistant suggested was the preferred term.  If these services were the same as suggested by the CPT Assistant article, then it would appear logical that the CPT Editorial panel would have used consistent terminology when creating these various codes.  The fact that they did not suggests that the CPT Editorial Panel (a distinct entity from the CPT Information Services division that publishes the CPT Assistant) recognized the differences between these technologies when it wrote and published these codes.

Additionally, there were a number of private communications between providers/carriers and CPT IS where CPT IS provided varying points of view.  While the AMA CPT IS division disclaims these private responses for use in benefit determinations or legal proceedings, it is clear that there was substantial confusion on this issue at the time the above referenced article appeared in the CPT Assistant.  Since the position expressed in the September 2000 CPT Assistant article suggests that videofluoroscopy was videofluorography in one portion of CPT but was specifically described as videofluoroscopy elsewhere in CPT, and such a position is contrary to CPT code convention, this article is not persuasive.

2. The FDA, subsequent to the AMA publication in 2000, has determined that videofluorography/cineradiography and videofluoroscopy devices are substantially different, and the diagnostic purpose (in terms of anatomic structures evaluated and conditions that can be diagnosed) of each is also substantially different. These differences are evidenced by the fact that the FDA has established separate 510(k) device classifications for each.  Videofluoroscopic devices are classified at 21 C.F.R. §892.1650 (Image intensified fluoroscopic x-ray system) while cineradiographic and videofluorographic devices are classified at 21 C.F.R. §892.1620 (Cine or spot fluorographic x-ray camera).  While this, in itself, is not determinative, it is persuasive that these devices are not the same as alleged in the AMA CPT Assistant article of September 2000 and supports the current descriptive differences that exist in CPT described in more detail below.  

3. Even if we assume that the September 2000 position was persuasive on the issue, two changes have occurred in CPT to invalidate the position expressed in the September 2000 edition of CPT Assistant ,which equated videofluoroscopy with fluorography/cineradiography. In 2002, the Introductory text of CPT was changed with respect to instructions for use. The following text was added:

 “Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code.”

As a result of this change, selection of a code that is “close” is no longer appropriate. As such, it appears that the conclusion expressed in the September 2000 CPT Assistant, that close is good enough, could only find justification in the standard of the time. Unfortunately, that justification is no longer valid.

Based on this change in the instructions, in 2002, the appropriate method of reporting diagnostic fluoroscopy would have been 76499.

A second relevant change occurred with the publication of the new CPT manual in 2003.  In 2003, the AMA created a new code - CPT 76496 that is described as follows: “Unlisted fluoroscopic procedure (eg, diagnostic, interventional)”.  Given the express inclusion of an unlisted “fluoroscopic” service code that, by its express terms, includes diagnostic or interventional fluoroscopic services, the position expressed in the September 2000 edition of CPT is even further invalidated. While CPT had previously included other fluoroscopic service codes, these were limited to interventional fluoroscopic services.  The creation and publication of this new code, which, by its description, is limited to videofluoroscopy, cannot include videofluorography or cineradiography as there is an existing code for these services. Similarly, CPT 76120, which describes cineradiography and videoradiography, cannot be interpreted to describe videofluoroscopy given the CPT instruction requiring that a service be exactly described by the service code.  Since CPT 76496 exactly describes the diagnostic videofluoroscopic service provided by the DMX unit issue in this case, it (76496) is the only correct code for this service.

4. In 2004, yet another opinion was published in the Question/Answer portion of the CPT Assistant in response to the exact same question that you posit above.   American Medical Association, CPT Assistant, Radiology, 76499 (Q&A), p. 15 (April 2004)  The AMA response is not persuasive and ultimately inaccurate for a variety of reasons as follows.  

a. First, the question does not reveal the fluoroscopic nature of the service.  The question describes the service at issue only as a “digital motion X-ray study procedure.”  Since the question does not reveal either the nature of the service, or the issues relevant to a proper analysis and determination, it cannot be assumed that CPT IS understood what service the DMX device performed and it is therefore not surprising that the result rendered was inaccurate.  

b. Second, the question asked whether CPT 76499 was the appropriate code, not 76496.  The question creates a Hobson's choice.  By avoiding the correct code, the AMA CPT IS employee answering this question was forced to choose between two incorrect codes.  

c. Third, the answer states that “[f]rom a CPT coding perspective, it would be appropriate to report 76120”. [Emphasis Added] Ibid.  The answer continues with the statement that this code “*may be *reported instead of the unlisted procedure code 76499...”.  Emphasis Added] Ibid.   Based on the instructions for use of CPT cited above, there can only be only one correct method of reporting a service.  The suggestion that CPT 76120 is an “appropriate” choice, and that it “may” be reported instead of another suggested choice, implies that either code could be used.  This is obviously incorrect rendering this reference completely unpersuasive in resolving this issue.

d. Finally, while the answer states that a “CPT coding perspective” was applied, as noted from the analysis above, the conclusion rendered by CPT IS deviates from CPT code selection standards published by the CPT Editorial Panel in CPT-4.  As such, the CPT IS conclusion is clearly inaccurate and therefore further invalidates this reference as providing any persuasive guidance as to the proper coding of diagnostic fluoroscopy performed with the DMX device.​
In conclusion, there is only one correct code choice where the method of selection is limited to the instructions and content of the CPT Manual.  Where CPT conventions are objectively applied, the only correct code for diagnostic videofluoroscopy is CPT 76496. The CPT Assistant references, which provide persuasive authority at best, are not determinative of this or any issue generally, and with respect to the specific issue in this case, are unpersuasive given that the conclusion rendered is not supported by the CPT code selection standards published by the CPT Editorial panel in CPT-4.  

While not raised in your question, there is often an additional question as to whether CPT 76496 may be reported in units.  While an unlisted service may not be reported in units under CPT convention, it is correct to report an unlisted code multiple times (different lines of the CMS-1500 form) provided that the subsequent billings were supported under the “separate procedure” requirements of modifier 59 and modifier 59 was appropriately applied to the subsequent billings for the same date. Specifically, where the study was of a different anatomic region or the study was performed at a separate session, the study of the second anatomic region or separate session is reported on a separate line with modifier 59 appended.

I hope this not only answers your question, but provides you with an analytical framework from which to evaluate any coding question.  I should note that where the CPT Assistant is expressly detailed in the statutory or contractual reimbursement scheme as a controlling standard for purposes of making a coding determination, the result is far from clear.  As demonstrated, there are substantial problems with the opinions expressed in the CPT Assistant such that these opinions are easily challenged.

Michael D. Miscoe JD, CPC, CHCC


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## pattytpa

*Thanks!*

Michael,

Thanks for the input, it does vary from the CPT assistant, but I'm thankful for you response.


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## mmiscoe

*Additional Information re: Synonymous Term Standards*

As a follow-up, here is some additional evidence that the CPT Assistant conclusion that fluoroscopy and fluorography/cineradiography/videoradiography are synonymous is inaccurate, especially after 2002.

In the 2002 CPT Changes, the AMA CPT Editorial panel included a section addressing synonymous terms and stated that as part of the CPT-5 project it had analyzed CPT-4 descriptors and that the “National Library of Medicine’s Metathesaurus was used to achieve baseline standardization of the CPT long descriptors synonymous terms/concepts.”  It revised a number of CPT code descriptors in 2002 as a result and provided a list of those codes that were changed.  CPT 76120 was not among the list of codes that were changed. As a result, we cannot conclude that fluoroscopy or videofluoroscopy is synonymous with videoradiography, videoflourography, or cineradiography as stated in the 2000 CPT Assistant article on this subject.  If they were synonymous, the description of CPT 76120 would have been changed. Regardless, the National Library of Medicine’s Metathesaurus was evaluated and it is confirmed that fluoroscopy and videofluoroscopy are not synonymous to videoradiography, videofluorography, or cineradiography.  The following are the search results from the metathesaurus:

Cineradiography: Listed synonyms are movement radiography, cinefluorography, radiocinematography and videofluorography.  As is clear, cineradiography and videofluorography are synonymous with each other; however, fluoroscopy and/or videofluoroscopy clearly are not.

Videofluoroscopy: there are no listed synonyms other than the term itself (i.e. videofluoroscopy).

Fluoroscopy:  Listed synonyms are fluoroscopic imaging, fluoroscopic imaging – action, fluoroscopic imaging – action (qualifier value), fluoroscopic imaging procedure (procedure), fluoroscopy NOS (procedure), fluoroscopy technique, and imaging fluoroscopy.

As is evident, there is no synonym correlation between fluoroscopy/videofluoroscopy and either cineradiography, videofluorography, or videoradiography.  To the extent that the author of the CPT Assistant article in 2000 assumed that these terms were synonymous at that time, the CPT Editorial Panel invalidated such an assumption in 2002 when it adopted the National Library of Medicine’s Metathesaurus as its standard for defining synonymous terms.  As a result, this change, along with the change to the instructions for use (also in 2002) completely invalidated the position expressed by CPT IS in the September 2000 edition of the CPT Assistant.  

No doubt, the April 2004 Q&A conclusion seems to indicate an affirmation of the conclusion on this issue reached in 2000.  The conclusion that diagnostic fluoroscopy performed using the DMX device should be coded using CPT 76120; however, is not supported by the changes in CPT convention established by the editorial panel in 2002.  Beyond the issues identified in my earlier posting regarding the errors in the April 2004 conclusion as to this service, it is clear that the CPT IS employee drafting the Q&A response in April 2004 failed to properly analyze the issue.  He or she overlooked the changes to the Instructions for Use published in 2002 as well as the Editorial Panel’s adoption of the metathesaurus for defining synonymous terms.  Had they done a complete analysis of the issue as is represented in the post above as amended by the information presented in this posting, they would have been forced to conclude absolutely that CPT 76496 was the correct code for diagnostic fluoroscopy services performed using the DMX device.

This is an interesting object lesson in proper code analysis.  For the Florida PIP cases where this issue has been predominant, the CPT Assistant is ultimately irrelevant as it is not a binding standard under the relevant statute.  To the extent that the CPT Assistant might, however, be considered persuasive, it would only be so where the conclusion it expressed was justified under the standards established by the CPT Editorial panel.  As this is clearly not the case here, the CPT Assistant conclusion cannot be considered persuasive and should be discarded in determining the appropriate code result for those cases.  

Fortunately, not all coding issues are this complex; however, because some are, it underscores the need for certified coders to be able to distinguish controlling (binding) coding standards for a particular case from those that are merely persuasive.  Additionally, coders should get in the habit of validating the conclusions expressed in any persuasive standard; even one that is used so commonly as the CPT Assistant, before citing that standard as offering a persuasive basis for selecting a particular code.  Finally, it should be remembered that one can never declare error for failure to code in conformance with a persuasive standard.  I hope this helps.  

Michael D. Miscoe JD, CPC, CASCC, CUC, CHCC


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