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Radiology Coding Alert

Challenge Your CT Skills With This Real-Life Case Study

Published on Thu Oct 04, 2007

Don't panic: We've got the truth behind this 'no indications for contrast' puzzle

If you crave feedback on your coding skills without the hassle of denials and audits, here's your chance. Try your hand at this CT report, and then see whether your answers match the pros'.


Lock in Your Code Choices

Start by analyzing the following report from an imaging center, and decide which CPT, ICD-9 and HCPCS codes you would report on the center's global service claim.

Exam: CT neck with contrast

Indication: Left vocal cord paralysis

Technique: Axial CT cuts were obtained from the top of the orbits down to the thoracic inlet using 100 cc of Isovue 300. 1.3-mm axial CT cuts were also obtained through the larynx. Sagittal and coronal computer reconstruction images were also obtained.

Indications for use of non-ionic contrast: None reported

Findings: No mass lesion within the posterior nasopharynx or oropharynx. There are multifocal punctuate calcifications in the right palatine tonsil. The submandibular and parotid glands are unremarkable. There are subcentimeter anterior cervical and left submandibular lymph nodes. There are subcentimeter left internal jugular lymph nodes. The left pyriform sinus is slightly larger than the right, and there is dilatation of the left laryngeal ventricle. There is probably atrophy of the left true vocal cord best seen on the 1.3-mm thick images. The left arytenoid cartilage has a more medial position than the right. The thyroid glands are unremarkable. The visualized upper mediastinum is unremarkable.

Impression: 1) Left vocal cord paralysis, 2) No cervical mass or adenopathy.



Size Up Your CPT Solution

For this exam, you should report 70491 (Computed tomography, soft tissue neck; with contrast material[s]), says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, vice president of Florida-based Southeast Radiology Management and president of Florida HIM Association.

You can't automatically depend on the "Neck CT with contrast" header to choose your code, but the report describes neck anatomy and intravenous contrast, confirming that the neck CT with contrast code is correct.

Remember: You should never choose a code based on the report's header, says Sheldrian Leflore, BA, CPC, revenue management educator with California-based The Coding Group.

You need to base your choice on the report documentation, she says.

Beware: The report says that "sagittal and coronal computer reconstruction images were also obtained." You should not report 76376-76377 (3D rendering with interpretation and reporting of computed tomography ...) because converting an axial scan into the coronal or sagittal plane is 2D reformatting. CPT guidelines specify that you may not report 2D formatting separately.


Follow These ICD-9 Accuracy Tips

You'll have to overcome a few obstacles to choose the most accurate diagnosis code for this service, which includes the finding of "left vocal cord paralysis."

ICD-9 limits your vocal cord paralysis choices to 478.3x (Paralysis of vocal cords or larynx).

Problem: The radiologist documented that the vocal cord paralysis was left side only, but to choose the most specific code, you also need to know whether the paralysis is partial or complete.

Solution: If you can't get a confirmed diagnosis from the ordering physician, you should report the unspecified code, Buck says: 478.30 (Paralysis of vocal cords or larynx; paralysis, unspecified).

Rule: Use the fourth or fifth digit when ICD-9 requires it, says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla.

Why: Correct coding requires that you code as specifically as possible. You cannot justify a service with a three-digit code when ICD-9 offers a four-digit code. You also can't use a four-digit diagnosis code when ICD-9 requires a more specific five-digit code to describe the patient's condition.

As in our case study, if you don't have specific information, you should choose the four- or five-digit code that says "unspecified," "not otherwise specified" (NOS), or "other."


Don't Miss These Contrast Unit Tips

To achieve the "with contrast" portion of this exam, the provider administered 100 cc of Isovue 300 (non-ionic contrast) intravenously. If you bear the drug's cost, then you should report the contrast with Q9949 (Low osmolar contrast material, 300-349 mg/ml iodine concentration, per ml).

The descriptor says to report the code "per ml," so you should report 100 units for the 100 cc administered. Why: One milliliter (ml) equals one cubic centimeter (cc).

Remember: CPT defines "with contrast" for imaging as contrast administered intravascularly, intra-arterially or intrathecally. If the patient received only oral or rectal contrast, you would not choose a "with contrast" imaging code option.

Note: The report says, "Indications for use of non-ionic contrast: None reported." But this missing information isn't an issue. "The restrictive criteria for LOCM (low osmolar contrast material) went away a few years ago," Buck says.


Round Up Your Codes

Your claim should include the following codes:

  • 70491 (1 unit) tied to 478.30
  • Q9949 (100 units) tied to 478.30, if your practice supplies the contrast.

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