Radiology Coding Alert

"In making preliminary evaluations of a thyroid disorder, an ultrasound often will be conducted (CPT 76536 , echography, soft tissues of the head and neck [e.g. thyroid, parathyroid, parotid], B-scan and/or real time with image documentation). Then more extensive exams are ordered, depending on conclusions drawn from the ultrasound. Each of these procedures demands careful coding to ensure that a radiology practice receives optimum reimbursement.

Diagnosing and treating thyroid disease was recently in the news when doctors caring for Tipper Gore, wife of Vice President Al Gore, discovered a nodule located on her thyroid gland. Gore underwent a thyroid lobectomy to remove the growth, which was found to be benign. Radiologists commenting on this course of treatment point out that there are several less invasive diagnostic procedures that frequently are used to determine the nature of nodules like Gores.

According to Harvey A. Ziessman, MD, director of nuclear medicine in the department of radiology at Georgetown University Medical Center, the two most common diagnostic procedures used are thyroid scans (with or without uptake) and needle biopsies, and they often are performed in conjunction with one another. When coding thyroid procedures, coders must recognize that an uptake study was done and, if so, whether single or multiple determinations are made. Coders also should note if no imaging is done in addition to the uptake. Finally, when assigning codes to biopsy procedures, they must be alert to the type of service provided, as well as a variety of guidance technologies that could be used.

Coding Nuclear Radiology Thyroid Scans

Among the conditions that may indicate thyroid scanning are swelling, mass, or lump in head and neck (784.2), which was Gores diagnosis; goiter, unspecified, enlargement of thyroid (240.9); abnormal loss of weight (ICD-9 783.2 ); tachycardia, unspecified (785.0); and palpitations (785.1).

The procedure consists of a nuclear radiologist administering radioactive iodine. After a number of hoursusually four or sixradiation levels are measured (defined as the uptake study) and/or the gland is imaged. If the nodule is hot or takes up more radioactive iodine than the rest of the thyroid gland, he notes, we are able to rule out malignancy with a high degree of certainty. However, if the nodule is cold and exhibits little or no uptake, there is a 15 to 20 percent probability of malignancy.

Correct coding of a radioactive iodine thyroid procedure is determined by:

1. whether a single or multiple determination uptake study is conducted, and

2. whether imaging takes place.

The most commonly assigned code is 78006 (thyroid imaging, with uptake; single determination), says Donna Richmond, CPC, of Acadiana Computer Systems, a medical billing management company based in Lafayette, La., which serves more than 200 radiologists, pathologists and anesthesiologists. This is the code that would be used when the radiologist administers the radioactive material to the patient, measures the radioactive uptake once and uses imaging.

Code 78007 (thyroid imaging, with uptake; multiple determinations) would be assigned for the injection, imaging and multiple uptake measurements, she adds. A typical scenario describing multiple determinations would occur when the nuclear radiologist measures the radioactive iodine levels at both six hours and 12 hours following administration.

Less frequently, Richmond adds, the physician may opt to measure only the uptake, foregoing imaging. If this occurs, you would assign code 78000 (thyroid uptake; single determination) if one uptake measurement was taken and 78001 (thyroid uptake; multiple determinations) if multiple determinations were made.

Coding Needle Biopsies of Thyroid Nodules

If the nodule shows little or no uptake and we know there is a chance that cancer exits, we would move to the next step: needle biopsy, Ziessman says.

Two distinct codes may be assigned for this procedure, Richmond adds. The doctor may decide to do a core biopsy, which involves removing a relatively large piece of tissue. The procedure code for this approach would be 60100 (biopsy thyroid, percutaneous core needle). However, others may perform a fine needle aspiration, where a limited number of cells are drawn from the mass. This would be assigned code 88170 (fine needle aspiration with or without preparation of smears; superficial tissue [e.g., thyroid, breast, prostate]).

In either circumstance, Richmond says guidance may also be used. One of the following codes would be assigned in addition to the surgical procedure, as appropriate:

76003fluoroscopic localization for needle biopsy or
fine needle aspiration

76360computerized tomography (CT) guidance
for needle biopsy, radiological supervision and
interpretation

76942ultrasonic guidance for needle biopsy,
radiological supervision and interpretation

Tip: Richmond reminds coders that even if the radiologist makes multiple passes at a single nodule, the biopsy codes may be assigned only once per lesion biopsied. However, if multiple lesions are biopsiedperhaps one on each lobe of the thyroidcodes may be assigned for each.

Case Study: Nuclear Radiology Thyroid Scans Clinical data: Thyroid nodules. Exam: Nuclear medicine thyroid uptake and imaging; 41A and 41B010400radionuclide six hour I-123 thyroid uptake: study was performed utilizing 300mCl of I-123 sodium iodide. The patients uptake measures 26.8 percent" " which is abnormally increased and should not be greater than 25 percent. Findings: Evidence of abnormal increased tracer uptake in the middle and lower portions of the left lobe of the thyroid gland" " interpreted as an autonomous hyperfunctioning thyroid nodule with diffuse diminished tracer uptake in the right lobe of the thyroid gland. Also in the upper left lobe of the thyroid gland" interpreted as being due to suppression of uptake due to the autonomous hyperfunctioning thyroid nodule left lobe of the thyroid gland. The nodule corresponding to a probable mass estimated approximately 2.5cm in diameter " located in left lobe of thyroid gland. Impression: Abnormal study as described above" " consistent with hyperfunctioning thyroid gland. Recommend further evaluation by endocrinologist. CPT: 78006 (thyroid imaging" with uptake; single determination)

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