Radiology Coding Alert

Correct Coding Initiative (CCI) version 14.0 added to the already bulky list of 3-D rendering edits, keeping you on your toes when you're considering reporting these codes. Now's the perfect time to take a look at what's new and be sure you're up on the other can't-miss 3-D rendering rules.

CPT 2006 added the following 3-D rendering codes:

• 76376 -- 3-D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation

• 76377 -- ... requiring image postprocessing on an independent workstation.

For 76376, which does not require an independent workstation, the physician discusses the need for 3-D imaging with the technologist and supervises the images' creation. For 76377, which does require an independent workstation, the physician supervises or creates the 3-D image and adjusts the projection for optimal anatomy and pathology visualization, says Michael Longacre, a consultant with HealthCare Market Strategies Inc. in Yamhill, Ore., citing ACR 2006 Coding Update.

Documentation tip: The only way that you can tell which code to report is if the radiologist documents independent workstation use (or nonuse), says Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga.

CPT added the 3-D rendering codes for complex renderings, including shaded surface rendering and maximum intensity projections (MIPs), fusion of images from other modalities and quantitative analysis (segmental volumes and surgical planning), Longacre says, citing the AMA's CPT Changes 2006: An Insider's View.

Remember: You should not separately report 2-D reconstruction, Longacre says. This change occurred in 2006 when CPT replaced 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computed tomography, magnetic resonance imaging, or other tomographic modality) with 76376 and 76377.

So even if your radiologist documents constructing coronal, sagittal, multiplanar or oblique reformats from axial images, remember that these are 2-D, and you should not report them separately, says Stacie Buck, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management.

Problem: "Our customers and advisers have indicated that a significant proportion of their 3-D procedures are not properly coded, billed or reimbursed," says Pierre Lemire, president and CTO of Calgary Scientific Inc. Medical Group, a 3-D advanced visualization software developer.

One factor is that documentation doesn't clearly support coding 76376 and 76377.

Helpful: Technological solutions that integrate software more tightly into billing and reimbursement workflow may help you keep track of documentation musts, boosting coding efficiency and reimbursement ratios. Example: Calgary Scientific is looking into IHE- and HL7-compatible audit trails and automated, structured reporting tools to help providers include all required orders to substantiate your coding submissions, Lemire says.

The January 2006 Journal of the American College of Radiology (JACR) advises that "when providing 3-D rendering services, particularly in the outpatient setting, a specific order is particularly helpful in defending a radiologist against allegations of 'churning' unnecessary services, as is explicit documentation in the report as to why such services were performed."

Back to basics: The ACR recommends the following for 3-D code use, Longacre says, citing the January 2006 Journal of the ACR:

1. medical necessity

2. a specific order, particularly for outpatient setting

3. documentation, either in a separate section or separate report, mentioning the 3-D rendering and what it showed independent of the originating exam.

Your local or regional carrier may have different rules, so check your payers' rules before coding, Longacre says.

Another element required for 76376 and 76377 is concurrent physician supervision of image postprocessing, 3-D manipulation of volumetric data set and image rendering, Longacre says.

According to the AMA and the ACR, concurrent supervision requires actively participating in and monitoring the reconstruction process, which includes the following, Buck says:

• designing the anatomic region to be constructed

• determining tissue types and structures to display

• determining images or cine loops to archive

• monitoring and adjusting 3-D work product.

Watch out: The concurrent supervision definition is independent of CMS' established supervision levels, Buck says.

The Medicare fee schedule states that the supervision concept does not apply to professional and global 76376 and 76377. The technical component of 76376 has supervision level "01," general supervision, which requires physician direction but not presence. Code 76377's technical component has supervision level "03," personal supervision, requiring physician attendance in the room during the procedure, Buck says.

You should check both CCI and CPT before reporting the 3-D codes. Effective Jan. 1, CCI 14.0's 3-D rendering edits clarify that you should not report 76376 and 76377 with CAD code +0159T (Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI [list separately in addition to code for primary procedure]) or the new cardiac MRI codes 75557, 75559, 75561 and 75563:

Override: Each of these edits has a modifier indicator of "1," meaning that you may override the edit in certain circumstances.

Watch out: You won't see cases requiring you to override the edits very often, Miller says. But there will be rare occasions in which a patient could undergo a cardiac MRI in the morning, followed by a 3-D ultrasound or 3-D CT (not CTA) later in the day, for example. "In that situation, you could appropriately apply modifier 59 (Distinct procedural service) to the 3-D code," she says.

Head to http://www.cms.hhs.gov/NationalCorrectCodInitEd/ to download the full list of edits, including the roughly 200 for 3-D rendering codes.

Don't miss: In addition to CCI, you can find many codes you can't report with the 3-D rendering codes in the CPT manual. These codes include postprocessing, and the fee schedule factors 3-D rendering values into those codes, Longacre says.