Oncology & Hematology Coding Alert

Confirm the reason for CT with PET before you code.

If you code imaging services for your patients, be sure to check your claim against the most recent Correct Coding Initiative (CCI) edits to identify codes that don't belong on your claim.

Watch for these CT edits among the 2,500 new bundles in version 18.2, which became effective for physicians July 1, 2012.

1. Check Medical Necessity Before Reporting CT With PET

The edits: CCI 18.2 adds these edits:

• Column 1: 78811-78813, Positron emission tomography (PET) imaging ...
• Column 2: 74176, Computed tomography, abdomen and pelvis; without contrast material.

Modifier indicator: These edits have a modifier indicator of 1, so you may override the edits with an appropriate modifier when circumstances allow (see the Tip below).

Edit rationale: The reason for the edits is "Misuse of Column 2 code with Column 1 code," according to the NCCI 18.2 Update by Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group.

Tip: Before you override the edit, be sure you aren't falling into the misuse trap:

Ensure that the CT is for diagnostic purposes and is not for attenuation correction or anatomical localization related to the PET scan. You want to be certain you aren't reporting separate PET and CT codes when it would be more appropriate to report 78814-78816 (Positron emission tomography [PET] with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging ...).

Append modifier 59 (Distinct procedural service) to 74176 when overriding the edit is appropriate.

Remember that you will need to have documented medical necessity for both the PET and the distinct CT. You also should have an order for each separate study.

2. Steer Clear of Reporting Heparin With CTA

The edits: The latest version of CCI wants to make sure you don't separately report the heparin used to maintain vascular access during computed tomographic angiography (CTA). Code J1642 (Injection, heparin sodium, [heparin lock flush], per 10 units) is now bundled into:

• 72191, Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
• 74174, Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
• 74175, Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing.

Modifier indicator: These edits have a modifier indicator of 1.

Edit rationale: These edits also seek to correct misuse of the Column 2 codes with the Column 1 code, Cohen states.

Tip: Remember the CCI principle that procedure codes include the services integral to them. Medicare's CCI policy manual states that many procedures require vascular access. "After vascular access is achieved, the access must be maintained by a slow infusion (e.g., saline) or injection of heparin or saline into a 'lock.' Since these services are necessary for maintenance of the vascular access, they are not separately reportable with the vascular access CPT® codes or procedures requiring vascular access as a standard of medical/surgical practice."

3. Don't Double Dip on 74177/74178 Pay

The edits: CCI 18.2 also creates the following edits:

• 74177, Computed tomography, abdomen and pelvis; with contrast material(s)
• 74178, ... without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions

• 76380, Computed tomography, limited or localized follow-up study
• 96360, Intravenous infusion, hydration; initial, 31 minutes to 1 hour
• 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
• 96374, Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug.

Modifier indicator: These edits have a modifier indicator of 1.

Edit rationale: The reason given for the 76380 edits is "Misuse of Column 2 code with Column 1 code." All of the other edits fall under the category of "Standards of medical/surgical practice," Cohen indicates.

Tip: The CCI policy manual explains that you should not report 76380 "with other computed tomography (CT), computed tomography angiography (CTA), or computed tomography guidance codes for the same patient encounter." Instead, an example of appropriate use of 76380 could involve a patient having an abdomen/pelvis CT (74177) in the morning. Then because of a change in condition in the afternoon, the patient requires a follow-up CT (76380-59).

For the other edits, "Standards of medical/surgical practice" means the Column 2 service is an integral part of the Column 1 service. As a result, the reimbursement for the Column 2 service is already factored into the Column 1 reimbursement, and you shouldn't report the integral service separately. In other words, because 74177 and 74178 both require contrast administration, that service is included in the CT. However, remember that if you bear the cost of the supply of contrast, you may report the appropriate HCPCS supply code in addition to the CT code for reimbursement.