Radiology Coding Alert

If you're looking for guidance on whether you may report 3D rendering with breast MRI CAD, you aren't alone. Try your skills with this example, based on a case sent in by a Florida radiology coder, to see how well you've been keeping track of these codes' changes.

Clinical history: Patient presents with history of bilateral mastectomy for breast cancer six years ago with no signs of recurrence, status post implant reconstruction with clinical suspicion of implant rupture on the left.

Technique: Axial T1 and fat sat T1 and T2 weighted images were obtained. Additional silicone suppressed axial images were obtained. Sagittal fat sat T2 weighted images were also obtained. Following the administration of 14 ml of MultiHance, axial fat sat T1 weighted images were obtained at 2.5, 3, 4, 5 and 6 minutes post-injection.

Subtraction sequences were then reviewed. Images were reviewed on a dedicated DynaCAD breast MRI workstation for flow dynamics image subtraction multiplanar and maximum intensity projection reconstructions ...

Findings: Bilateral breast implants are demonstrated. The implants show silicone signal characteristics with a small amount of water signal surrounding each silicone implant. There is evidence of rupture of the silicone component of the left implant with admixture of water with silicone as well a redundancy of membrane with so-called keyhole sign. No residual glandular tissue is observed in the overlying reconstructed breast following the administration of gadolinium, no abnormal enhancement is observed along the chest wall or in the internal mammary chain.

Opinion: 1. Status post bilateral mastectomy with implant reconstruction with evidence of intracapsular rupture of left-sided implant. 2. No evidence of chest wall or internal mammary recurrence.

To report the bilateral breast MRI, you should use 77059 (Magnetic resonance imaging, breast, without and/or with contrast material[s]; bilateral), says Stacie Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management.

Remember that hospitals cannot use 77059 for outpatient Medicare billing. The hospital should report C8908 (Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral).

The doctor also documents reviewing the images on a "dedicated DynaCAD breast MRI workstation for flow dynamics image subtraction multiplanar and maximum intensity projection reconstructions." For this service, you should report +0159T (Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI [list separately in addition to code for primary procedure]).

Watch for: Code 0159T includes all post-processing imaging, so you should not report 3D reconstructions separately, according to the January/February 2006 ACR Coding Source, Buck says.

Unfortunately, most payers don't cover CAD, and those few that do pay $3 to $25 for the professional fee, Buck says. On the other hand, the professional fee for 3D rendering code 76377 tops out at roughly $46. Remember: Accurate coding requires 0159T.

Your first-listed diagnosis should be 996.54 (Mechanical complication of other specified prosthetic device, implant, and graft; due to breast prosthesis), and then report V10.3 (Personal history of malignant neoplasm; breast).

ICD-9 guidelines instruct you to report a "history of" code once the patient has completed all treatment, says New Mexico-based coding consultant Melanie Witt, RN, CPC-OGS, MA.
Here's the exact language: "When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code" (http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf).

Translation: If treatment has eradicated the patient's breast neoplasm so that the neoplasm no longer requires treatment, you should use V10.3 rather than 174.x (Malignant neoplasm of female breast).

Coding roundup: You should report 77059 (or hospitals should report C8908 for Medicare), 0159T, 996.54 and V10.3 for this case.