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Radiology Coding Alert

CCI Rings in New Year with Significant Radiology Edits

Published on Fri Feb 01, 2002

Radiology coders must pay close attention to new edits implemented by the Correct Coding Initiative (CCI) version 8.0 effective Jan. 1, 2002. The modifications bundle a number of component codes into comprehensive procedures, rendering it inappropriate to report each service independently for payment. According to Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialties, the most-affected codes are from the radiation oncology section of CPT, along with a number of procedures that now include fluoroscopy, 3-D reconstruction and computerized tomography (CT) services that were previously billed separately.

Edits Affect Radiation Oncology

"The changes made in radiation oncology are considered devastating to many in the field," Parman says. Radiation oncologists and freestanding treatment centers were delighted with the addition of two new codes describing intensity modulated radiation therapy (IMRT) planning and treatment in CPT Codes 2002:
 
77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
 
77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams (e.g., binary, dynamic MLC), per treatment session.

The codes describe important new services and were assigned high relative value units (RVUs) 77301 carries 39.13 fully implemented nonfacility total RVUs, while 77418 carries 16.18.
 
But much of the delight has been undercut with the CCI Edits, which bundle in nearly every possible related service. "We had feared this would happen, and it is very disappointing," says Parman. "The edits bundle in isodose planning, CT studies, treatment delivery, special dosimetry, treatment devices, therapy management, special treatment procedures, everything. These edits have taken codes that paid well and turned the situation completely around."
 
Office visits have also been bundled into many radiation oncology codes, leaving consultations (99241-99245) as the only E/M service that may be billed separately. "Radiation oncologists and coders will need to be very careful to ensure they follow the rules about what constitutes a consultation before they submit those charges," says Stacey Hall, RHIT, CPC, CCS-P, director of corporate coding for Medical Management Professionals Inc., a national billing and management firm for hospital-based practices in Chattanooga, Tenn.

Fluoroscopy and 3-D Reconstruction Edits

While CPT 2002 included a plethora of cross-references explaining when fluoroscopy code 76003 (Fluoroscopic guidance for needle placement [e.g. biopsy, aspiration, injection, localization device]) is bundled into other services, Hall says, the new edits further clarify the inclusion of fluoroscopy within the radiology supervision and interpretation (RS&I) services as provided in most clinical procedures. For instance, 74320 (Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation), 74350 (Percutaneous placement of gastronomy tube, radiological supervision and interpretation) and 74355 (Percutaneous placement of enteroclysis tube, radiological supervision and interpretation) among other RS&I codes all include fluoroscopic guidance. On the rare occasions when clinical circumstances demand additional fluoroscopy on the same date of service as an RS&I service, modifier -59 (Distinct procedural service) should be used and supported by thorough clinical documentation.
 
Similarly, 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computerized axial tomography, magnetic resonance imaging, or other tomographic modality) has now been wrapped into a range of other services, Parman says. Among the new comprehensive codes are 75945 (Intravascular ultrasound [noncoronary vessel], radiological supervision and interpretation; initial vessel) and 75989 (Radiological guidance for percutaneous drainage of abscess, or specimen collection [i.e., fluoroscopy, ultrasound, or computed axial tomography], with placement of indwelling catheter, radiological supervision and interpretation). In addition, many of the infant and fetal diagnostic codes now also include the 3-D reconstruction code (e.g., 76818, Fetal biophysical profile; with non-stress testing).
 
Hall notes that radiology coders need to try to go through the entire CCI edit file to make sure they no longer report component codes that are now included in a more comprehensive procedure.

Edits Greatly Affect Digitization and CT Codes

Two other changes are particularly noteworthy, Parman adds. Code 76085 (Digitization of film radiographic images with computer analysis for lesion detection and further physician review for interpretation, screening mammography [list separately in addition to code for primary procedure]), which was added in 2002, will be bundled into diagnostic mammography codes 76090 (Mammography; unilateral) and 76091 ( bilateral). "CPT +76085 may be reported as an add-on code with screening mammography (i.e., 76092, Screening mammography, bilateral [two view film study of each breast])," she explains, "but is considered bundled into the diagnostic mammography code."
 
Likewise, 75635 (Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, radiological supervision and interpretation, without contrast material[s], followed by contrast material[s] and further sections, including post-processing) now incorporates two CT codes that some reported separately in the past: 72191 (Computed tomographic angiography, pelvis, without contrast material[s], followed by contrast material[s] and further sections, including image post-processing) and 74175 (Computed tomographic angiography, abdomen, without contrast material[s], followed by contrast material[s] and further sections, including image post-processing). "Many practices see these as very separate procedures and are used to reporting them this way," Parman says. "This edit signifies an important change."
 
However, Parman adds, there are occasions when even these component codes may be provided as separate and distinct services and correctly reported in addition to the newly identified comprehensive codes. "Some of these edits carry a CCI indicator of '1,' which means a modifier may be appended to bypass the edit. Modifier -59 may be added when the service identified with a component code is performed at a different session or on a different anatomical site, for example. "Coders must realize, however, that they cannot simply add modifier -59 to avoid the edit. It must meet the criteria allowing the modifier to be used."
 
Conversely, many of the new edits carry an indicator of "0," which means you cannot use a modifier to get paid for the component code in addition to the comprehensive code.

Changes Made to CCI Introductory Language

A broader change is contained in the CCI 8.0 introductory material, Parman notes. Chapter 1 outlines a requirement that modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) be added to distinct E/M services (e.g., 99212, Office or other outpatient visit, established patient) that are provided on the same day as procedures that carry an "XXX"-day global period. These XXX procedures are diagnostic tests like x-rays and similar services provided by radiologists (e.g., 73630, Radiologic examination, foot; complete, minimum of three views).
 
She adds that this requirement may affect some interventional radiologists, who are more likely to provide E/M services. "It's important to remember that a significant and separately identifiable E/M service must be provided in addition to a procedure for both to be reported," she says. Medicare states in the CCI that a certain degree of interaction with the patient is inherent in certain radiology procedures, and physicians cannot additionally report an E/M unless a higher level of service (i.e., significant service) is provided." Inherent in a procedure, Parman says, is time spent with the patient to obtain limited pertinent history, determine the presence of allergies, provide adequate information to acquire informed consent, review the medical procedure, and conduct follow-up assessments if necessary.
 
This change was, in essence, implemented and rescinded in October 2000 with version 6.3 of the CCI edits. At that time, this modified policy was outlined in thousands of new edits, which created confusion and caused their suspension. The new approach for 2002 accomplishes the same objective but with less disorder. "The earlier attempt, however, required that the -59 modifier be appended to whichever code in the bundled pair was considered comprehensive," Parman says. "The language this year instead requires that the -25 modifier always be added to the E/M service."

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