Radiology Coding Alert

If your practice performs pre-ordered multiple kidney studies (one with pharmacological intervention and one without) on different days, you should report just one unit of CPT 78709 to avoid double-dipping. Be sure that the patient's chart demonstrates why you separated the two services and why they were medically necessary.

It's one of the most complex aspects of radiology coding: The physician can't decide which tests will best benefit the patient until after he or she reads prior radiology reports. You can't report tests that the physician orders, however, if you don't perform them. Sheila Rosenfeld, MA, CNMT, FSNMTS, director of the nuclear medicine teleimaging network at St. Louis Veterans Administration Medical Center, offers the following example:

A patient presents to the nuclear medicine department for a renal scan to determine whether the patient has renal artery stenosis (440.1). Nuclear medicine performs the renal scan with pharmacological intervention but does not administer an ACE inhibitor because the patient is already on one. After finishing her report, the physician requests a baseline kidney imaging study. Nuclear medicine performs the baseline study one week after the original study.

Which of the following coding scenarios is the best possible choice?

A. Report 78707 for the first study and another unit of 78707 for the second study. If the radiologist did not use pharmacological intervention for the first study or the second study, 78707 (Kidney imaging with vascular flow and function; single study without pharmacological intervention) would technically be the accurate choice for both studies. Because this code clearly indicates that the radiologist performed no pharmacological intervention, however, some coders feel that reporting it would be a misstatement of fact, as they view the ACE inhibitor as pharmacological intervention.

B. Report 78708 for the first study and 78707 for the second study. The National Correct Coding Initiative (NCCI) bundles 78707 into 78708 (Kidney imaging with vascular flow and function; single study, with pharmacological intervention [e.g., angiotensin converting enzyme inhibitor and/or diuretic]), but only if the radiologist performs both studies on the same day. Technically, these codes are both accurate if the radiologist uses pharmacological intervention during the first study.

C. Report 78709 once to describe all services included in the multi-day study. Because 78709 (Kidney imaging with vascular flow and function; multiple studies, with and without pharmacological intervention [e.g., angiotensin converting enzyme inhibitor and/or diuretic]) includes both the initial study and the subsequent baseline study, it describes both services performed, says Kay Tracy, BS, RCC, lead coder at the Oregon Clinic's radiology department.

To determine which coding scenario is most accurate, the practice should determine the physician's intent, says Gary Dorfman, MD, FACR, SIR, president of Health Care Value Systems in North Kingstown, R.I.

Rationale for Choices A or B: "The nuclear medicine department would normally coordinate with the referring physician to ensure that the patient has discontinued all medications that might interfere with the study," Dorfman says. "If the physician decides to perform the initial study with the patient on an ACE inhibitor, I would recommend coding it as 78707, because the radiologist did not perform any acute pharmacological intervention specifically for the purpose of the imaging test."

If, after the radiologist performs, interprets and reports the initial study, the physician decides to remove the patient from his ACE inhibitor and perform another single study, the practice should report either 78707 or 78708.

"You would choose 78707 for the second study only if nuclear medicine performs a scan without any intervention, and 78708 in the unlikely event the radiologist performed another pharmacologic study," Dorfman says.

He therefore advises reporting 78707 for the first date of service and 78707 for the second date, provided that the radiologist does not administer pharmacological intervention. Remember, these choices are only accurate if the ordering physician ordered the follow-up study after reading the initial study's results.

Rationale for Choice C: If, from the outset, the physician intended to perform a staged study with the patient on an ACE inhibitor on the first date, and a follow-up study with the patient off of all medications on the second date, you should report only 78709, Dorfman recommends.

"The claim would not require any more justification than if the physician ordered 78709 to be performed on a single date of service," he says. "This is analogous to a multi-phase cardiac stress test with the rest study performed on one day and the stress on another."

Because the correct code choice comes down to physician intent, it is very important that the patient's chart clearly document the ordering physician's original request. If, from the beginning, the physician requested both baseline and follow-up studies, you cannot report 78707 twice on different dates of service.

Some carriers might view this as "unbundling" because your practice would net about $210 for 78707, and another $210 the following week when you rerun the study. You should not, therefore, report these two codes separately unless the physician truly requests the second study after reading the original report.

If you report 78709, your carrier will pay about $230. Although this represents nearly $200 less than reporting 78707 twice, you will avoid accusations of "double-dipping" and "coding for dollars" if the radiologist knew all along that the patient required both studies.