Radiology Coding Alert

If you assume that CPT 78306 is bundled into 78320, you could be writing off $115 per patient

If denials for planar bone scans performed with SPECT imaging puzzle you, improper pairings of 78300 and 78320 could be at the source. Our experts answer the most pressing questions about these nuclear medicine codes so you can maximize reimbursement for these expensive procedures.
 
Question 1: We performed a limited bone imaging (78300) and a SPECT bone imaging (CPT 78320 ). Can we report both to Medicare?

Radiologists typically perform limited bone or joint imaging on a single body part, such as a wrist, while SPECT allows the physician to reproduce the images in three dimensions using a computer. If the physician identifies an abnormality during the limited bone study, he might further explore the abnormality using SPECT during a separate session.

Coding solution: If the radiologist performs both procedures during separate sessions on the same date of service, you can report both codes, as long as you append modifier -59 (Distinct procedural service) to 78300 (Bone and/or joint imaging; limited area). The National Correct Coding Initiative bundles 78300 into 78320 (Bone and/or joint imaging; tomographic [SPECT]), so if you don't append modifier -59 to 78300, Medicare will deny the claim. If the physician performs both procedures concurrently, however, you cannot report 78300.

Some coders neglect to report both codes together, even if the physician performs both procedures during separate sessions, says Randall Karpf, owner of East Billing in East Hartford Conn. "Insurers don't always take it upon themselves to tell practices when they can and can't use modifier -59 to undo an CCI Edits ," Karpf says. "Plus, Medicare guidelines often advise practices not to report certain codes together, so the practices don't bother to check the NCCI edits to confirm whether or not a modifier is a valid way to report both codes during separate sessions."

The facts: The March 1997 issue of CPT Assistant , for instance, states, "The bone SPECT code 78320 is not to be used in addition to the other planar bone imaging codes 78300 and 78305 (Bone and/or joint imaging; multiple areas)." But the NCCI edit carries a "1" indicator, which confirms that you can use a modifier to separate the services when documentation clearly supports separate patient encounters.

You can recoup about $305 when you report 78320 and about $135 for 78300, increasing your reimbursement significantly if the physician's documentation demon-strates the separate and distinct nature of the two services.

Remember that the Department of Health and Human Services Office of Inspector General included modifier -59 as a focus area in its 2004 Work Plan, so you should  append modifier -59 only if the individual patient medical-record documentation supports completely distinct services on the same date of service (such as a separate session).

Your documentation should also demonstrate why your practice could not perform the complete service during a single episode of care. Merely separating the two imaging services into two sessions without medical justification is insufficient documentation.

Question 2: Are there any bone scan procedures that Medicare will reimburse if we perform them with a SPECT during the same session?

NCCI does not contain any edits barring you from reporting 78306 (Bone and/or joint imaging; whole body) with 78320, so this is the only bone scan code pair that you can report without appending modifier -59.

"One scenario where this would occur is when the patient presents with low back pain," says Bruce Hammond, CRA, CMNT, chief operating officer at Diagnostic Health Services Inc., a Texas-based radiology imaging service with locations in 15 states. "The lumbar x-ray is normal, the CT scan is normal, the whole-body bone imaging is normal, but you do the SPECT (78320) of the area and discover a fractured pedicle that hasn't repaired enough to be visible under x-ray and was too small to be seen in contrast to isotope uptake on a whole- body scan."

Reimbursement realities. Section 15022 of the Medicare Carriers Manual states that modifier -51 (Multiple procedures) applies to this nuclear medicine code pairing. Medicare will reimburse 78320 at its full rate of about $305 but will cut 78306 (which normally reimburses about $230) by 50 percent. Although this may seem like a drastic cut, practices that fail to report 78306 at all because they believe it (like the other body scan codes) is bundled into the SPECT code are missing out on $115 per patient. But remember that your documentation must demonstrate the medical necessity of both services.

Even though the MCM advises practices to append modifier -51 to 78306, some payers (particularly private insurers) prefer to add modifier -51 themselves. You should therefore confirm your insurer's guidelines before you report this code pair.

Question 3: Our radiologist documented a "scintigram" during the flow phase of a three-phase bone scan. Assuming that this is equivalent to SPECT imaging, can we report 78315-59 and 78320 for this service?

No. "Assuming" that you interpreted a physician's documentation appropriately can often lead to incorrect coding, and that's the case here. As with any medical terminology, if you don't know what a scintigram describes, don't assign a SPECT code to it until you confirm the procedure with the radiologist.

Solution: " 'Scintigram' is just another word for a nuclear medicine picture," Hammond says. "The detectors in nuclear medicine scans are scintillation detectors, and the pictures are accordingly called scintigrams." For this service, Hammond says, you should report only 78315 (Bone and/or joint imaging; three-phase study).

Question 4: Our carrier denied a follow-up scan for an osteomyelitis patient, even though the policy lists the osteomyelitis ICD-9 code (730.16) as payable for a whole- body scan (78306). Should I appeal?

Probably not. Most carriers will reimburse you for an initial whole-body scan to determine whether a patient has osteomyelitis and, if so, how many sites are affected. After that, the insurer will only reimburse follow-up scans that you perform on the affected sites.

Example: Cahaba GBI, a Part B carrier in Alabama, Georgia and Mississippi, publishes a policy that states, "Follow-up scans for patients with osteomyelitis should be limited to the involved area(s); whole-body imaging will be denied or downcoded to HCPCS 78300 (localized area) without additional documentation."

Because your ICD-9 code specifically identifies that your patient's osteomyelitis is centralized in his lower leg, you should only perform and report the limited scan code, 78300.