Radiology Coding Alert

Do CT abdomen and pelvis scans need 1 or 2 codes? Find out.

Providers often image malignant neoplasms and other areas of the patient’s body to evaluate if the tumor is growing or has metastasized (spread) into other parts of the body. Assigning the correct imaging codes comes down to understanding the AMA CPT^® guidelines and paying attention to notes in the code set.

Review the radiology report below to see if you can correctly code the case study.

Locate the Information You Need in This Radiology Report

The radiology report below is from a follow-up encounter for a patient diagnosed with a primary malignant neoplasm of the abdomen, right upper quadrant (RUQ). The patient’s physician ordered the computed tomography (CT) scans of the chest, abdomen, and pelvis to evaluate if the patient’s tumor has increased in size and if the disease has metastasized into other parts of the body.

Date: 7/8/20XX

Location: Local outpatient radiology clinic

Imaging Tests: CT chest w/ contrast, CT abdomen w/ contrast, CT pelvis w/ contrast

Comparison: CT abdomen captured at local outpatient radiology clinic 5/20/20XX

Patient History: Malignant neoplasm of the abdomen RUQ

Technique: Axial images of chest, abdomen, pelvis with oral and IV contrast

Impression:

1) Right upper quadrant primary malignant neoplasm increased in size.

2) No metastatic disease demonstrated.

3) Coronary arteriosclerosis.

Now that you’ve had a chance to review the radiologist’s report, your next step will be to determine the correct CPT^® and diagnosis codes to assign for your report.

Disclaimer: To conserve space, we removed the findings section of the report. In this scenario, presume the findings didn’t provide any additional information you’d need to complete your report. In a real-world coding scenario, you’d want to double-check the information in the findings against the impression to ensure there aren’t any discrepancies or contradictions between the sections.

Check the Guidelines for ‘With Contrast’ Confirmation

Before you jump into searching for the appropriate CT codes, you’ll want to review the guidelines prior to the Radiology codes in the AMA CPT^® code set. In the “Administration of Contrast Material(s)” section, you’re instructed to use codes featuring “with contrast” in their descriptors only for procedures involving intra-articular (into the joint), intravascular (into the blood vessels), or intrathecal (into the spinal canal) contrast injections.

The guidelines also state that “Oral and/or rectal contrast administration alone does not qualify as a study ‘with contrast.’”

For an encounter such as the one described in the case study, you’ll need to consider the use of contrast when selecting the CPT^® codes. “In this case, intravenous (IV) contrast was administered along with the oral contrast, so a ‘with contrast’ code would be utilized. If IV contrast was not utilized and only oral contrast was utilized, then a ‘without contrast’ code would be used,” says Taylor Berrena, COC, CPC, CEMC, CFPC, coder II at MD Anderson Cancer Center at Cooper in Yorktown, Virginia.

Don’t Get Tricked Into Choosing Too Many CPT^® Codes

The documentation lists three imaging procedures, but you’ll only need two CPT^® codes to report the CT scans. The CT of the abdomen and the CT of the pelvis are performed at the same time, and you can report the procedures using a single code.

In the AMA CPT^® code set index, search for CT Scan > with Contrast > Abdomen as well as Pelvis to locate the code options for each body area. The individual services are listed in the code set as:

• 74160 (Computed tomography, abdomen; with contrast material(s))
• 72193 (… pelvis; with contrast material(s))

While it may be tempting to use each of these codes for the services, you won’t use two codes to report these services. “Per the guidelines, which direct the coder to utilize the table listed in the 2022 CPT^® code set for code selection, when a CT of the abdomen and CT of the pelvis is performed at the same session, if a CT of the abdomen with contrast and CT of the pelvis with contrast were performed at the same session, then the combination code 74177 [Computed tomography, abdomen and pelvis; with contrast material(s)] should be reported,” Berrena says.

In addition to the table in the code set, there is a parenthetical note listed under both CT abdomen and CT pelvis code ranges directing you to the 74176-74178 (Computed tomography, abdomen and pelvis …) code range.

Next, you’ll need to assign the CT scan of the patient’s chest with contrast. In the CPT^® code set index, look to CT Scan > with Contrast > Thorax to locate the code that you can verify in the code set. You’ll assign 71260 (Computed tomography, thorax, diagnostic; with contrast material(s)) to report the CT scan with contrast of the patient’s chest.

Sequence Multiple Diagnosis Codes Correctly

The radiologist concluded that the malignant neoplasm in the RUQ of the abdomen has increased in size, and they reported an incidental finding of coronary arteriosclerosis. To correctly report these diagnoses, you’ll need to know how to sequence the codes. “Per the 2023 ICD-10-CM Official Guidelines, Section IV.K, the sequencing would depend on the ‘diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit,’” Berrena says.

At the same time, Section IV.K adds that you should “code any confirmed or definitive diagnosis(es) documented in the interpretation” for outpatient encounters for diagnostic tests that have been interpreted by a physician if you have the final report when coding. In this case the patient presented for a follow-up imaging scan of the abdominal malignant neoplasm, making C76.2 (Malignant neoplasm of abdomen) the first-listed diagnosis. Then, you may report I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris) as an additional diagnosis, following your organization’s policies on reporting incidental findings.

Wrap Up the Claim

How did you do? The codes assigned for the encounter are as follows:

CPT^®: 74177, 71260

ICD-10-CM: C76.2, I25.10.