Test yourself to be sure you've mastered this year's coding changes. Codes for abdominal and pelvic CTs are among those most frequently reported to Medicare by radiologists. In 2011, the addition of several codes means you have to choose among a mix of old and new options to report these services. Follow along with this sample case study, choosing the codes you would report for 2011 and seeing if they line up with the analysis below. Read the Report and Choose Your Codes Header: Dictated report: Indication: Technique: Findings: The liver, gallbladder, adrenal glands, spleen, pancreas, and kidneys are normal. The bladder is adequately distended without evidence for bladder wall thickening. Both ovaries are visualized, contain normal-appearing follicles. There is also a 2.1- x 1.4-cm physiologic cyst within the right ovary. The appendix is distended, contains a few 3- to 4-mm appendicoliths, demonstrates abnormal bowel wall enhancement, and is associated with moderate adjacent periappendiceal fat stranding. The remaining bowel is normal. No periappendiceal fluid collection or abscess. Impression: Narrow Code Choices Based on Anatomic Area In our sample report, the radiologist notes the state of the abdominal structures (liver, gallbladder, pancreas, intestines) and the pelvic structures (bladder, ovaries). Old way: New way: CPT® 2011 keeps 74150-74170 (abdomen only) and 72192-72194 (pelvis only), but because the sample case represents an abdominal and pelvic CT in the same session, you will be choosing from new codes 74176-74178, assuming this case has a 2011 date of service. Dig Into the Meaning of 'With Contrast' To select the proper code, you'll need to determine whether the provider performed the studies with contrast, without contrast, or without contrast followed by with contrast. Rule: For the sample report, the statement that slices were obtained after the administration of oral and IV contrast implies that both the oral and IV contrast were given before any imaging was done. "In that case, the documentation supports 'with' contrast instead of 'without and with,'" says radiology coding consultant Cheryl A. Schad, BA Ed, CPC, ACS-RA, PCS, President/CEO of Schad Medical Management in Mullica Hill, N.J. To report a code for studies without contrast followed by with contrast, the sample report would have needed "to clearly state that slices were taken without contrast (or with the oral contrast only) prior to IV contrast administration," Schad explains. Old way: New way: Remember to append modifier 26 (Professional component) if you're reporting only the physician's services and not the technical component. Round Out Your Claim With HCPCS and ICD-9 Your HCPCS and ICD-9 coding for this case will look the same as it has for the past several years. HCPCS: ICD-9: Size Up Secondary Diagnoses When reports include findings that are incidental (not causing the problem that needs medical attention), guidelines don't require you to code them, but you're allowed to report them as secondary diagnoses. In our sample report, that means you technically could add a diagnosis for the ovarian cyst (620.2, Other and unspecified ovarian cyst). You shouldn't report atelectasis (518.0, Pulmonary collapse), however, because the radiologist records this as "likely" atelectasis, which isn't a definitive diagnosis.