Radiology Coding Alert

Write up this ‘rule out appendicitis’ scenario to treat yourself to CEUs

If you get spooked by having to choose CT codes based on contrast use or deciding which diagnosis codes to claim, follow our experts step-by-step through this real report for tips on how to choose the proper code every time.

Header: Abdominal and pelvic CT with enhance, CT reformation body

Dictated report: CT of abdomen and pelvis

Indication: 26-year-old female with abdominal pain, rule out acute appendicitis

Technique: Contiguous axial images were obtained from the lung bases through the pubic symphysis following the uneventful administration of oral and intravenous contrast, 150 cc Isovue-300 at 3 cc/sec. FOV=32 cm.

Findings: Lung windows demonstrate subpleural opacity in the right lower lobe, likely representing atelectasis. No parenchymal nodule or mass within the visualized lung bases. No pleural or pericardial effusion.

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: Acute appendicitis.

Verify Contrast to Choose CPT

Smart start: If you quickly skim the report, you’ll see that you’re coding two complete examinations--a CT of the abdomen and a CT of the pelvis.

Your radiologist’s documentation must include discussion of the anatomical structures of both the abdomen and pelvis for you to code CT studies of both sites, says Sheldrian Leflore, CPC, an independent California coding consultant whose specialties include radiology. You also need to have orders for CT studies of both the abdomen and pelvis and documentation of medical necessity before you code.

In our sample report, the radiologist notes the state of the abdominal structures (liver, gallbladder, pancreas, intestines) and the pelvic structures (bladder, ovaries). As a result, you can narrow your CPT Codes choices to 74150-74170 (Computed tomography, abdomen ...) and 72192-72194 (Computed tomography, pelvis ...).

Next: To select the proper code from each range, determine if the provider performed the studies with contrast, without contrast, or with a complete examination prior to and after the administration of contrast.

“Oral and rectal contrast studies are not considered ‘with contrast’ studies,” says Carrie Caldewey, CPC, an experienced radiology coder and coding supervisor for Northern California Medical Associates in Santa Rosa, Calif. You’ll find this rule spelled out in your CPT manual in the CT guidelines, she adds.

The manual states that “contrast” refers only to contrast agents supplied intravascularly, intrathecally, or intra-articularly.
 
Our report indicates one set of images, with the use of intravenous contrast in addition to oral contrast. Result: You’ll be choosing codes that indicate CTs with contrast, Caldewey says:

•  74160--Computed tomography, abdomen; with contrast material(s)

•  72193--Computed tomography, pelvis; with 

Don’t overlook: If your practice pays for the contrast material, you should also report it with the appropriate HCPCS code. Example: Claim the Isovue-300 with the proper code for your payer, such as Q9949 (Low osmolar contrast material, 300-349 mg/ml iodine concentration, per ml) or A4646 (Supply of low osmolar contrast material [300-399 mgs of iodine]). The patient received 150 cc of contrast, so report 150 units (1 cc = 1 ml).

Experts warn: Never choose your codes based on the header, Leflore says. Instead: “Focus on the body of the report to ensure appropriate selection of the CPT code,” she says.

For example, in our sample report, the header states, “CT Reformation Body,” which could indicate reconstructing the images into a different plane (76375; Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computed tomography, magnetic resonance imaging, or other tomographic modality). The body of the report doesn’t provide documentation of this service, however, so you could be inviting an audit if you code 76375 with only the header to support your choice.

Don’t Settle: Require a Definitive Diagnosis

Red flag: Our CT is to “rule out” appendicitis, but you should never code a diagnosis because a physician wants to rule it out, Caldewey says.
 
The impression confirms acute appendicitis, without mention of peritonitis (540.9), but if you don’t have a definitive diagnosis, you should report signs and symptoms, Leflore says.

A chart for a patient who needs a CT to rule out appendicitis may reveal symptoms such as 789.03 (Abdominal pain; right lower quadrant), 787.01 (Nausea with vomiting), and 780.6 (Fever). But don’t assume--check documentation to be sure.

Size Up Secondary Diagnoses

If your report includes findings that are incidental--not causing the problem that needs medical attention--you aren’t required to code them, but it’s OK to report them as secondary diagnoses, Caldewey says. In our sample report, that means you may want to add a diagnosis for the ovarian cyst (620.2, Other and unspecified ovarian cyst).

You wouldn’t report atelectasis (518.0, Pulmonary collapse), however. Why: The radiologist records this as “likely” atelectasis, which isn’t a definitive diagnosis.

Coding round-up: After analyzing your report, you should report the following CPT and ICD-9 codes:

•  74160
•  72193
•  540.9
•  620.2--optional.