Radiology Coding Alert

Find out when coding a separate CT is above-board

PET/CT machines offer radiologists improved images, and good documentation of these services needs to be just as full of information. Here's a look at a report with real-life problems with tips on how to solve them.

Determine What's Missing From This Report

PET/CT skull base to mid-thigh

Fasting blood sugar at the time of injection was 96. Imaging performed 50 minutes post injection on the GE Discovery LS Hybrid PET/CT scanner with CT attenuation correction. Images reviewed in axial, coronal, and sagittal planes. 3D reconstructed model of the whole body was obtained and submitted for interpretation.

Findings: Whole-body PET/CT hybrid images show no focal increased metabolic uptake to indicate metastatic disease. Specifically there is no abnormal uptake seen in the small bilateral lung nodules seen on CT examination [date deleted]. No abnormal uptake in the mediastinum to suggest nodal metastatic disease. In the neck, there is physiologic uptake but no evidence of metastatic disease.

In the abdomen and pelvis, there is physiologic uptake seen in the GI tract in the left colon extending to the rectosigmoid. There is also physiologic uptake in these structures. No evidence of metastatic disease identified.

Impression: Negative whole-body PET/CT hybrid examination. No evidence of metastatic disease on this examination.

CPT: Compare the Header and Findings/Impression

The correct CPT code for this report is 78815 (Tumor imaging, positron emission tomography [PET] with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization; skull base to mid-thigh), says Lori Hendrix, CPC, CPC-H, coding consultant with Coding Strategies Inc. in Powder Springs, Ga.

What's right: The physician documented the procedure and scanner type clearly, Hendrix says.

What's wrong:  The header says, "PET/CT skull base to mid-thigh," but the Findings and Impression say, "whole-body PET/CT hybrid images," she says.

You should never code a report based on the header, but in this case you can't accept the Findings' or Impression's claim of "whole-body" automatically either.

The documentation does not support coding a whole- body scan, Hendrix says.

The radiologist discusses the lungs, the mediastinum (in the chest), the neck, and the GI tract in the abdomen and pelvis (left colon to rectosigmoid). Discussion of these structures supports coding a skull base to mid-thigh PET/CT (77815) rather than a whole-body PET/CT (78816, ....whole body).

Tip: Typically only melanoma patients receive whole- body scans, Hendrix says.

Another coding option to consider is 78814 (... limited area [e.g., chest, head/neck]). But because the radiologist documents findings in more than one limited area, you know that 78815 is the right choice.

ICD-9: Verify Diagnosis Before You Code

Although the procedure documentation is adequate, documentation of clinical history is completely missing from this report, meaning you have no way to know why the treating physician ordered this exam.

And because the findings are nondiagnostic, there's no diagnosis you can code.

The facility's files show that a few months ago the patient had a CT scan that was reported with diagnosis codes 197.0 (Secondary malignant neoplasm of respiratory and digestive systems; lung) and 153.3 (Malignant neoplasm of colon; sigmoid colon). But don't be tempted to use those codes automatically for this study.

Risk: You should never just pull diagnoses from a prior exam, Hendrix says. The diagnosis code(s) for each exam must reflect the reason why that exam was performed, and the only way to be sure this is the case is to get the clinical indications from the ordering physician.

For high-end exams like PET, MRI, and CT, make sure you have the clinical indications before doing the study. Otherwise, the facility can be left holding the bag if the patient turns out not to have a covered condition.

Better: Either you should be given access to the requisition, or the radiologist should be careful to include the clinical history from the requisition in the dictated report. That way you have access to complete information.
 
Add These Tips to Your PET/CT Toolbox

Suppose the patient's record reveals that he received a separate diagnostic CT on the same date he received the PET/CT.

Rule: When the physician documents a PET/CT and a separate diagnostic CT (not performed for attenuation correction or anatomical localization), you may report the diagnostic CT with the appropriate code and modifier 59 (Distinct procedural service), according to CPT guidelines.

You may not see this often, but the physician may want to scan a separate body area for another reason or the patient's condition may change, prompting the physician to perform a separate CT, says Bruce Hammond, CRA, CNMT, of Diagnostic Health Services in Texas.

Example: A patient receives a PET/CT of the head and neck (78814). Not long after, he has intense abdominal pain and the physician decides the patient needs an abdominal CT (74150, Computed tomography, abdomen; without contrast material).

Tech tip: Don't confuse PET/CT studies with 16- and 64-slice scanners, Hammond says. Your hybrid system is more likely to have a 1-, 4-, or 6-slice scanner. "The goal of fusion imaging is to have anatomical and physiological data in the same image, not necessarily to have the highest resolution CT possible," he says.