Radiology Coding Alert

Dig into the reason for PET + CT before choosing your codes.

Love them or hate them, Correct Coding Initiative (CCI) edits can help identify codes that don't belong on your claim. Version 18.2 became effective for physicians July 1, 2012, and brings a variety of changes for both diagnostic and interventional services. Here are the highlights, including the rationale behind each edit to help you apply the bundles with ease.

1. Check Medical Necessity Before Reporting CT With PET

The edit: CCI 18.2 adds these edits:

• Column 1: 78811-78813, Positron emission tomography (PET) imaging ...
• Column 2: 74176, Computed tomography, abdomen and pelvis; without contrast material.

Modifier indicator: These edits have a modifier indicator of 1, so you may override the edits with an appropriate modifier when circumstances allow (see the Tip below).

Edit rationale: The reason for the edits is "Misuse of Column 2 code with Column 1 code," according to the NCCI 18.2 Update by Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group.

Tip: Before you override the edit, be sure you aren't falling into the misuse trap:

• Ensure that the CT is for diagnostic purposes and is not for attenuation correction or anatomical localization related to the PET scan. You want to be certain you aren't reporting separate PET and CT codes when it would be more appropriate to report 78814-78816 (Positron emission tomography [PET] with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging ...).
• Append modifier 59 (Distinct procedural service) to 74176 when overriding the edit is appropriate.
• Remember that you will need to have documented medical necessity for both the PET and the distinct CT. You also should have an order for each separate study.

2. Modifier Indicator 0 Prevents 75954/0255T Error

The edit: The latest CCI version creates the following edit:

• Column 1: 75954, Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, using ilio-iliac tube endoprosthesis, radiological supervision and interpretation
• Column 2: 0255T, Endovascular repair of iliac artery bifurcation (e.g., aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; radiological supervision and interpretation.

Modifier indicator: The edit has a modifier indicator of 0, which means you may never override the edit.

Edit rationale: CCI lists 75954 and 0255T as mutually exclusive procedures, according to Cohen.

Tip: The term "mutually exclusive" means CMS believes the "procedures cannot reasonably be performed at the same anatomic site or same patient encounter," states the National Correct Coding Initiative Policy Manual for Medicare Services (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html).

3. Get Specific With Imaging Code for 55876

The edit: You'll find that 55876 (Placement of fiducial markers into the prostate gland for radiation guidance) is a Column 1 code for these Column 2 guidance codes:

• 76000, Fluoroscopy (separate procedure), up to 1 hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy)
• 76001, Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician (e.g., nephrostolithotomy, ...)
• 76998, Ultrasonic guidance, intraoperative.

Modifier indicator: All three edits carry a modifier indicator of 1, which means you may override the bundles in certain circumstances, such as when the fluoroscopy was provided for another procedure at a separate session.

Edit rationale: The 76000 edit rationale is listed as "CPT® 'separate procedure' definition." In other words, because 76000 includes "separate procedure" in the definition, you should report 76000 only for fluoro provided independent of any other same-day services you're reporting. The reason given for the 76001 and 76998 edits is misuse of those codes with 55876.

Tip: These edits make sense, says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri, Department of Surgery, in Columbia. "In most cases, our doctors will use 76872 (Ultrasound, transrectal) and/or 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for the placement of the markers."

4. Match G0269 Edits to Code Guidelines

The edit: The latest CCI edits bundle G0269 (Placement of occlusive device into either a venous or arterial access site, postsurgical or interventional procedure [e.g. angioseal plug, vascular plug]) into endovascular revascularization codes 37220-+37235.

Modifier indicator: These edits have a modifier indicator of 1.

Edit rationale: The reason given for the edits is "CPT® manual or CMS coding instructions."

Tip: CPT® guidelines state that endovascular revascularization codes 37220-+37235 include arteriotomy closure with use of an occlusive device, which supports the rationale for the edit. Also keep in mind that Medicare does not reimburse physicians for G0269.

5. Steer Clear of Reporting Heparin With CTA

The edit: The latest version of CCI wants to make sure you don't separately report the heparin used to maintain vascular access during computed tomographic angiography (CTA). Code J1642 (Injection, heparin sodium, [heparin lock flush], per 10 units) is now bundled into:

• 72191, Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
• 74174, Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing
• 74175, Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing.

Modifier indicator: These edits have a modifier indicator of 1.

Edit rationale: These edits also result from misuse of the Column 2 code with the Column 1 codes.

Tip: Remember the CCI principle that CPT® procedure codes include the services integral to them. The CCI manual states that many procedures require vascular access. "After vascular access is achieved, the access must be maintained by a slow infusion (e.g., saline) or injection of heparin or saline into a 'lock.' Since these services are necessary for maintenance of the vascular access, they are not separately reportable with the vascular access CPT® codes or procedures requiring vascular access as a standard of medical/surgical practice."