Radiology Coding Alert

Contrast, contributions, complete exam, service components, and clear impressions are key.

When reporting diagnostic radiology procedures, you will find yourself submitting codes for various different modalities. Your physician may obtain an X-ray or perform an advanced diagnostic procedure like diagnostic ultrasound, computed tomography (CT), magnetic resonance imaging (MRI). Some other advanced diagnostic approaches may include positron emission tomography (PET) and mammography.

Check payer policies: When reporting any of these procedures, always remember that you have checked for policies of public and private payers and your claims are compliant with the payer specifications and requirements. You may also request the payer requirements in writing for ease of understanding. This will help you to submit accurate claims and avoid any unnecessary denials.

You Can’t Miss the Minimum Requirements: The American College of Radiology (ACR) provides guidance for radiology reports. Your report should clearly state the procedure done, the numbers and sequence of views along with names of the views examined, for example, anteroposterior, lateral, and oblique views for X-rays. Equally important is that the report mentions the clinical indication for which the radiological procedure is being performed.

Any report is incomplete without details of findings during the procedure performed. Finally, the report should conclude on a synopsis or summary of findings with a clear impression of the radiological assessment.

Finally, ensure that all your radiology reports have physician signatures.

1. Keep Count of Views

When you report a CPT^® code for radiological examination, you should report the number of views required to submit the code. Your physician may have defined and listed some “standard views,” or the number of views to be imaged for the radiology office. You cannot use these listings for coding purposes. Make sure the documentation for radiological reports clearly state the number of views. You then accordingly look for the most suitable code to cover the number of views examined.

Example: When your physician obtains X-rays of hand, you should count the views examined and submit codes accordingly. The code 73130 (Radiologic examination, hand; minimum of 3 views) specifies that minimum of three views should be documented. You submit code 73130 when your physician examines the hand in anteroposterior, lateral, and oblique views. However, you may come across radiological reports where your physician does not mention the count (three, in this example) of the views, instead lists the views examined. In either case, the documentation is considered appropriate to support submission of code 73130.

There may be radiological reports in which your physician neither mentions the count nor the views specifically. You may read that your physician has only documented ‘multiple views of knee.’ In such a situation, you report the lowest-level corresponding CPT^® code for the particular study, i.e. code 73560 (Radiologic examination, knee; 1 or 2 views).

Referring physician order is no exception: The requirement for listing views applies to referring physician orders, too. If the views or the number of views are not listed in the order, the radiology office should contact the referring physician and ask for a new order indicating the views needed in the examination. The radiology unit or office cannot generalize department norms for obtaining a certain number of views, example: minimum three views in X-rays of hand.

2. Check Contrast to Choose Code

Do not miss the contrast in upper gastrointestinal radiological examinations and in CT and MRI assessments.

Single vs. double contrast studies: Single and double contrast refers to the type of contrast that was administered during the gastrointestinal study. Your physician administers a thin barium sulfate contrast during a single contrast study. A double contrast implies that the barium sulfate used in the examination is thick and heavy density. In addition, the patient may be needed to ingest effervescent crystals with water. When this mixture is swallowed, the air from the crystals fills up the stomach and the thicker barium coats the stomach wall. This clearly defines the lumen and the lining of the stomach and the radiologist can look for any irregularities suggestive of ulcers.

Similarly, when you report barium enema for a colon study, you need to confirm if your physician used a single or double contrast. Single contrast in the colon examination implies that your physician instilled a thin mixture of barium sulfate and water into the patient’s rectum. On the other hand, a double contrast barium enema implies that your physician first instilled heavy density barium into the colon. In the next step, your physician will pump air into the colon and coat the walls of the bowel with the barium.

Note: When your radiologist does a cervical esophagram examination for the upper part of the esophagus, you do not separately report this examination as this is bundled to single and double upper gastrointestinal studies. You can however submit the esophagus study codes 74210 (Radiologic examination; pharynx and/or cervical esophagus) - 74230 (Swallowing function, with cineradiography/videoradiography) with modifier 59 (Distinct procedural service) in addition to the upper gastrointestinal imaging studies.

Think IV for contrast: When billing for administration of contrast for radiological examination, note that oral or rectal administration doesn’t count as contrast. For CT and MRI examinations, contrast implies that your physician administers it by the intravenous route. The technique section of the radiological report should clearly mention an ‘IV’ or ‘intravenous’ contrast.

What is a scout view: Scout view, also called the KUB (Kidney, Ureters, and Bladder) view, is a single supine view of the abdomen taken prior to gastrointestinal examinations. When your physician obtains a KUB film, you must ensure that the documentation must state the findings of the scout view.

Whether or not your physician performs a preliminary abdominal KUB, you can submit the specific procedure codes.

3. Isolate Professional and Technical Components

Most radiology procedures include both a technical component and a professional component. This is a fundamental in radiology coding and you should be very specific about what services your physician did. You need to know whether to report a technical, professional, or “global” service.

Technical component: The technical component (TC) of a service includes the provision of all equipment, supplies, personnel, and any costs related to the performance of the exam. When you are reporting only the technical portion of a service, you append modifier TC (Technical component).

Hospitals are exempt for TC: Note this important exception for technical component. When your physician performs any services in a hospital, it is assumed the hospital is billing for the technical component of each radiological procedure. Hospitals are hence exempt from reporting modifier TC.

Professional component: The professional component of a service includes the work of your physician for providing a dictated report or any supervision of the procedure. When you report only the physician work portion of a service, you append modifier 26 (Professional component).

Remember, when you append modifier 26, you should ideally place it in the first designated modifier field. This will affect how the claim will be paid.

Global service: You bill for global service when your physician bears the expense of supplies and equipment, provides supervision, and also prepares the report for the radiological procedure. You generally bill for global services in an office setting, where your physician group owns the equipment and provides the final signed reports.

Note: Do not submit modifiers TC and 26 when you are reporting for global services.

Example: Here is an example for technical and professional components. If your physician reads a two-view chest X-ray in the hospital, you would report 71020 (Radiologic examination, chest, 2 views, frontal and lateral) with modifier 26. This is because the radiologist only provides a final impression of the X-ray findings in a signed report.

If however, your radiologist supplies the equipment for X-ray in his own office, you submit code 71020 without modifiers. This is because you bill for the global service in this situation.

Do not forget these additional supplies: When you are reporting any diagnostic nuclear medicine studies and PET, bear in mind that the study codes do not include radiopharmaceuticals. Hospitals and physician offices should report the radiopharmaceutical supplies separately using the correct supply code(s).

4. Earn for Supervision and Interpretation

You will find some study code descriptors, e.g., 74328 (Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation) and 74330 (Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation), including the service of ‘supervision and interpretation’ that your physician does.  These studies may be performed by another physician and interpreted by your radiologist. In this situation, you can submit the study codes and append modifier 52 (Reduced services) to the CPT^® code for the procedure. The other physician may also bill the service similarly. The modifier implies that neither of the two billing physicians solely performed/interpreted the procedure.

5. Ensure Complete Documentation for ‘Complete Exam’

To be able to earn for ‘complete exam’ ensure you have documented all necessary parameters. This applies specifically to abdominal and retroperitoneal radiological studies.

All diagnostic ultrasound examinations require permanent image documentation. Abdominal and retroperitoneal studies have additional, strict documentation requirements to code for a complete exam.

Complete ultrasound abdomen: When you submit code 76700 (Ultrasound, abdominal, real time with image documentation; complete) for a complete ultrasound of the abdomen, you need to ensure the radiological impressions for the upper abdominal aorta and inferior vena cava, kidneys, liver, gall bladder, common bile ducts, pancreas, and spleen. If you miss out on any of these in the supporting documentation, you will miss being paid for the complete exam. Defaulting at any of these parameters brings your claim down to a limited exam. You submit code 76705 (Ultrasound, abdominal, real time with image documentation; limited [e.g., single organ, quadrant, follow-up]) for limited abdominal ultrasound examination.

Similarly, a complete retroperitoneum ultrasound examination includes documentation for radiological assessment of the kidneys, abdominal aorta, and common iliac artery origins. You submit code 76770 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; complete) for complete retroperitoneal examination on ultrasound.

Note: When your physician does an ultrasound for the indication of a urinary pathology, the imaging of the kidneys and urinary bladder also constitute a complete retroperitoneal study.