Radiology Coding Alert

A little runoff CTA know-how can help prevent a lot of denials.

You have a new code to consider for abdominal/pelvic CTA claims in 2012. Get up to speed on proper use, guidelines, and coding edits with this quick primer.

Ease Into 74174 With 74176-74178 Comparison

CPT® 2012 introduced a new code that's appropriate when you need to report abdominal and pelvic CTA performed concurrently: 74174 (Computed tomographic angiography, abdomen and pelvis, with contrast material[s], including noncontrast images, if performed, and image postprocessing).

In those cases where the radiologist performs only an abdominal CTA or only a pelvic CTA, you should apply the individual code that represents the specific service performed:

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

These CTA options echo the CT changes CPT® 2011 introduced with 74176- 74178, (Computed tomography, abdomen and pelvis ...), noted CPT® Editorial Panel member Richard Duszak, MD, FACR, FRBMA, RCC, in the Radiology presentation at the CPT® and RBRVS 2012 Annual Symposium.

Codes 74176-74178 are appropriate for concurrent abdominal/pelvic CT, but you have individual codes available if the physician performs only abdominal CT or only pelvic CT.

One difference between the CT and CTA codes is that your CT options vary based on use of contrast:

• Without: 74176, Computed tomography, abdomen and pelvis; without contrast material
• With: 74177, ... with contrast material(s)
• Without/with: 74178, ... without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions.

For CTA, you have only one option, and it specifies with contrast, including noncontrast if performed. The reason is that "it is impossible to perform CTA without contrast," Duszak explained. Still, as the code definition states, any noncontrast images performed are included in 74174. "A few noncontrast images are typically taken to calibrate the scanner and to identify the anatomic region to be evaluated, but that is not a requirement for the reporting of a CT angiography code," states CPT® Assistant (April 2008).

Beware Forbidden Code Combinations

Before you pair a code with 74174 on your claim, double check Correct Coding Initiative (CCI) edits and CPT®'s parenthetical notes that apply to the code.

Specifically, a parenthetical note with 74174 tells you not to report the code in conjunction with the following:

• 72191, Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
• 73706, Computed tomographic angiography, lower extremity, 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
• 75635, Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing
• 76376, 76377, 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality ...

To help you adhere to these guidelines, CCI bundles each of the above bulleted codes with 74174, as described below. The edits are effective as of Jan. 1, 2012.

72191, 74175: It should come as no surprise that CCI bundles 72191 (pelvic CTA) and 74175 (abdominal CTA) into 74174, which was designed to capture pelvic and abdominal CTA performed together. The edits have a modifier indicator of 1, meaning you may override the edit with a modifier when documentation supports reporting the services separately.

76376, 76377: New code 74174 also includes 3D reconstruction, so you should not report 76376 or 76377 separately, Duszak said. The CCI edits for these codes have a modifier indicator of 0, so you may never override them.

Take a Closer Look at 73706 and 75635 Ban

To understand why CPT® and CCI instruct you not to report 74174 (abdominal/pelvic CTA) with 73706 (lower extremity CTA) or 75635 (runoff CTA), you need to understand which services 75635 captures.

According to CPT® Assistant (April 2011), 75635 captures CTA of the "abdomen, pelvis, and bilateral lower extremities." As a result, you should report only 75635 for that combination.

You should not report the individual codes for the components (such as 74174, 73706) -- this would be inappropriate unbundling.

If you attempt to report 73706 (lower extremity CTA) with 74174 (abdominal/pelvic CTA), a new CCI edit will trigger a denial for 73706. You'll also be at risk of improper coding allegations if 75635 was the appropriate code for the service performed and documented.

FYI: The 74174/73706 edit has a modifier indicator of 1, so you may override the edit when documentation supports doing so.

Codes 75635 (runoff CTA) and 74174 are also bundled, but for this edit, 74174 is in the column 2 position. If you report both column 1 code 75635 and column 2 code 74174 on the same claim, payers who apply CCI edits will pay the column 1 code (75635) and deny the column 2 code (74174). This makes sense when you recall that 75635 is intended to capture the services described by 74174 and more. This edit has a modifier indicator of 0, so you may never override the edit.

Caution: CPT® includes a parenthetical note with 74174 that you should report CTA aorto-iliofemoral runoff using 75635. Remember that this means you should report only 75635. The note does not mean that you should report 75635 in addition to 74174 for aorto-iliofemoral runoff.

Smart move: The review of CCI edits above is only the start. The most recent CCI version adds 37 CCI edits with 74174 in the column 1 spot, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group, in his NCCI Change Analysis 18.0, available from www.frankcohengroup.com/Library/ResearchandStudies.aspx (you may need to register to view the document). So avoid denials by checking your claims against the edits prior to submission. The current edits are also available for download from www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.