Radiology Coding Alert

Changes may be on the horizon for virtual colonoscopies, thanks to an American College of Radiology Imaging Network (ACRIN) trial. And being up-to-date on all of radiology's new technologies -- and covered category III codes -- is up to you.

Here's what you need to know about reporting these services now.

CT colonography (virtual colonoscopy or CTC) is an enhanced abdominal CT scan in which computer reconstruction allows radiologists to perform a detailed longitudinal 3D bowel examination for polyps, cancer or other disease. This procedure uses helical computed tomography of the abdomen and pelvis, along with 3D reconstruction, to visualize the colon lumen. The test requires colonic preparation similar to that required for standard colonoscopy (instrument colonoscopy) and air insufflation to achieve colonic distention.

For this service, you'll report CT colonography codes 0066T (Computed tomographic [CT] colonography [i.e., virtual colonoscopy]; screening) or 0067T (... diagnostic), says Rhonda Townley, CPC, with Association of University Radiologists in Knoxville, Tenn.

Important: These Category III codes are global codes, meaning they include both the technical (modifier TC, Technical component) and physician reading fee (modifier 26, Professional component). Remember to append 26 if the radiologist only interprets the CT and doesn't meet technical component requirements, such as owning the CT machine and covering staffing costs.

Also, note that the procedure includes 3D reconstruction. That means you should not report 3D reconstruction codes 76376-76377 with the CT colonography codes.

Medicare does not cover 0066T, the screening CT colonography code. But CMS periodically revises screening benefits, and many think 0066T coverage may soon change.

Here's why: "Most physicians and much of the public have embraced full colon imaging as the optimal colorectal cancer prevention approach because the whole colon is at risk and because polyp detection and removal prevents cancer before it starts," says Douglas K. Rex, MD, professor of medicine at Indiana University Medical Center in Indianapolis.

"With the publication of the American College of Radiology Imaging Network trial, guideline groups will likely reconsider CTC as an option for screening," and you'll see a "renewed pressure for a Category I CPT code," Rex says.

Plus: The American Cancer Society recently updated its screening guidelines to recognize virtual colonoscopy as a cancer-screening tool (http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp#coloncancer).

You may have more luck with receiving reimbursement for diagnostic CT colonographies (0067T). Payers often won't cover Category III codes -- designating the procedures as experimental. But if you have your supporting ICD-9 codes and documentation in perfect order, your pocketbook could be in for a pleasant surprise. Here's what to watch for.

Typically a patient would have an exam if he has a personal or family history of colon polyps, diverticulosis or colon neoplasms, Townley says.

Codes for these conditions include the following:

• V10.05 -- Personal history of malignant neoplasm; large intestine

• V12.72 -- Personal history of certain other diseases; colonic polyps

• V16.0 -- Family history of malignant neoplasm; gastrointestinal tract

• V18.51 -- Family history of certain other specific conditions; colonic polyps

• 562.1x -- Diverticula of intestine; colon.

Crucial: You should check your payer's policy to learn which conditions -- not just diagnoses -- you must meet for the payer to consider CT colonographies medically necessary.

For example, National Heritage Insurance Company (NHIC) of California "does not consider routine use of CT colonography for diagnosis to be an established intervention that is reasonable and necessary." Instead, NHIC considers CT colonographies medically necessary when "diagnostic optical colonoscopy has failed or is incomplete due to obstruction, and where the results of CT colonography are likely to impact further patient management."

In other words, when a patient with signs or symptoms of a disease undergoes an incomplete diagnostic optical colonoscopy (because of neoplasm, stricture, tortuosity, spasm, redundant colon diverticulitis, extrinsic compression or aberrant anatomy scarring from prior surgery), the ordering physician may turn to CT colonography (0067T) as a solution.

You'll run into trouble if you try to report 0067T in the following cases.

First, you won't earn any reimbursement if you report 0067T with V76.51 (Special screening for malignant neoplasms; colon). This code (0067T) refers to a diagnostic procedure, not a screening one.

Second, because any colonography with abnormal or suspicious findings requires a colonoscopy for diagnosis (such as a biopsy) or treatment (such as a polypectomy), payers will not pay for CT colonographies as an alternative to a colonoscopy -- even though your radiologist may have performed this service for signs or symptoms of a disease.

"Irritable bowel syndrome and abdominal pain when representing chronic stable symptoms rarely represent reasonable indications for colonoscopy and CT colonography," according to NHIC. You can use them as diagnoses "when a colonoscopy/colonography exam is normal in the face of compelling symptoms." But watch out -- your physician will have to carefully document the rationale in the medical record.

Best advice: "Watch your insurance companies for criteria, because they are very strict -- especially Medicare," says Kelli Pekios, a patient accounts manager in Moline, Ill.