Radiology Coding Alert

The latest round clears up brain MRI coding, but not same-vessel intervention controversy

Correct Coding Initiative (CCI) version 14.1 focuses many of its more than 2,000 edits on radiology codes. You could spend hours weeding through the latest round of edits, but we've already done the deciphering for you in these seven tips.

Take a look at the diagnostic and interventional radiology edits you need to incorporate into your coding, effective April 1.

1. Stick to Designated 32998 Guidance Codes

CCI 14.1 includes edits for guidance codes that you shouldn't use for radiofrequency ablation (RFA), says radiology coding expert Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

The next time you report guidance for lung ablation (32998, Ablation therapy for reduction or eradication of one or more pulmonary tumor[s] including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral), double-check the codes CPT guidelines instruct you to use:

• 76940 -- Ultrasound guidance for, and monitoring of, parenchymal tissue ablation

• 77013 -- Computed tomography guidance for, and monitoring of, parenchymal tissue ablation

• 77022 -- Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation.

Some coders have been misusing 76998 (Ultrasonic guidance, intraoperative) and 77021 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection or placement of localization device] radiological supervision and interpretation) with 32998, according to CCI 14.1.

Result: CCI established the following nonmutually exclusive edits to clean up your RFA guidance coding:

Remember: Payers will cover only the column 1 code if you report a nonmutually exclusive edit pair together. The modifier indicator "1" means that you may override the edit with an appropriate modifier if you meet certain conditions, such as the services taking place at different sessions or anatomical sites.

2. Choose Vertebroplasty-Specific 72292

To put a stop to misusing CT guidance codes 76380 (Computed tomography, limited or localized follow-up study) and 77011 (Computed tomography guidance for stereotactic localization) with 72292 (Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance), CCI now bundles both 76380 and 77011 into 72292. This edit has a "1" modifier.

What to do: You should report CT guidance for vertebroplasty procedures with only 72292, Miller says.

3. Think Before Reporting Brain MRIs Together

CCI aimed to halt misusing intracranial MRI codes 70557-70559 with functional brain MRI codes 70554-70555, Miller says. The edits have a "1" modifier indicator. But you're unlikely to perform these services together, she says.

4. CCI Is Still Adding GJ-Tube Edits

CPT 2008 added 49446 (Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection[s], image documentation and report). And CCI 14.1 adds edits to prevent you from reporting moderate sedation codes 99143-99144 with 49446, Miller says.

These edits have a "0" modifier indicator, which means that you may never override the edit.

Tip: The CPT manual includes 49446 in Appendix G, the list of codes that include moderate sedation.

5. Expect Denials for A4641 With PET

When PET reports come your way, you have the following options for reporting radiopharmaceuticals, Miller says:

• A9552 -- Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries

• A9555 -- Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries

• A9526 -- Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries.

CCI wants to make sure you stick to these codes for PET claims instead of reporting A4641 (Radiopharmaceutical, diagnostic, not otherwise classified). Result: CCI bundles A4641 into PET scan codes 78459, 78491, 78492, 78608 and 78811-78813. It also bundles A4641 into PET/CT codes 78814-78816. All of these edits have a "1" modifier indicator.

6. CCI Clarifies More Extensive Kidney US

If you image a transplanted kidney, then you should report only 76776 (Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation), Miller says.

If you also report 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], real time with image documentation; limited), payers will cover only 76776 because of a new edit with a "0" modifier indicator.

7. Controversy Continues: Same-Vessel Procedures

"The most interesting thing about this version of CCI is what's not included," Miller says. CCI still hasn't created edits to enforce controversial language added to the CCI manual last October.

The change: In chapter 5 of the 13.3 manual, page v-11, you'll find the following language, says Stacie Buck, RHIA, CCS-P, LHRM, RCC, vice president of Southeast Radiology Management, in The Coding Institute audioconference "2008 Radiology Coding Update":

"If an atherectomy fails to adequately improve blood flow and is followed by an angioplasty at the same site/vessel during the same patient encounter, only the successful angioplasty may be reported. Similarly if an angioplasty fails to adequately improve blood flow and is followed by an atherectomy at the same site/vessel at the same patient encounter, only the successful atherectomy may be reported. If atherectomy and/or angioplasty fail to adequately improve blood flow and are followed by a stenting procedure at the same site/vessel during the same patient encounter, only the successful stenting procedure may be reported. These principles apply to percutaneous or open procedures."

Example: Documentation shows that a patient underwent unsuccessful angioplasty (35474, Transluminal balloon angioplasty, percutaneous; femoral-popliteal) and successful stenting (37205, Transcatheter placement of an intravascular stent[s] [except coronary, carotid and vertebral vessel], percutaneous; initial vessel).

You should report only one intervention per vessel under the 13.3 guideline. In this case, you should report the successful stent procedure, 37205.

This rule about not coding failed interventions is a big change for radiology coding, but it's similar to the rules for surgery and cardiac interventions, Buck says.

Play it safe: This 13.3 CCI rule conflicts with what many specialty societies and the AMA recommend, says Stacy Gregory, RCC, CPC, of Tacoma, Wash.-based Gregory Medical Consulting Services, who co-presented "2008 Radiology Coding Update."

But when you're reporting your providers' services to payers that follow CCI guidelines, you need to follow this 13.3 rule, Gregory says.

Eye on the future: Watch Radiology Coding Alert for updates on whether the CCI manual revises this rule.

Resource: You can get your own copy of "2008 Radiology Coding Update" at http://www.audioeducator.com/industry_conference.php?id=567.