Radiology Coding Alert

See examples covering various surgical scenarios.

If you’re confused on what exactly constitutes a radiological supervision and interpretation (RS&I) service, you’re not alone. You’ll find RS&I codes within nearly every subsection of the Diagnostic Radiology section of the CPT^® manual, yet you may not code them frequently enough to fully understand how one RS&I service may differ from another.

While the bare bones of an RS&I service may be uniform across all RS&I code sets, understanding how they may fit into different surgical situations can be a challenge.

Break down what constitutes an RS&I service — and then have a look at three real-world examples to clear up any lingering confusion.

Begin by Outlining Radiologist’s Role

The first point you’re going to want to consider regarding RS&I procedures is whether the radiologist performs the surgical portion of the service in addition to the RS&I portion. For instance, you may come across clinical scenarios in which an interventional or diagnostic radiologist will perform both the contrast injection and RS&I components of an arthrography exam. In other encounters, the radiologist will exclusively perform the RS&I component while a surgeon of another specialty performs the underlying procedure.

Once you’re able to make the determination of the extent of the radiologist’s involvement, all you’ve got to do next is come up with the appropriate CPT® codes to report. But sometimes that can be easier said than done.

Work Through Some Myelography Examples

To start, you’re going to have a look at some services that involve RS&I codes that are traditionally exclusively performed by a radiology provider. During a myelography exam, for instance, the radiologist will advance a spinal needle under fluoroscopic guidance for a contrast injection in the spine. Coding a myelography can differ from that of another RS&I service because, depending on what’s documented, you may be able to report an all-encompassing code. These codes include both the surgical component and the RS&I component.

For instance, if the myelography report includes the injection of contrast under fluoroscopic guidance and follow up X-ray/computer tomography (CT) imaging, you’ll report a single code such as:

• 62304 (Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral).

However, if the provider only documents the injection of contrast under fluoroscopic guidance without true radiographic or CT imaging, then you’ll report one code for the injection and another for the fluoroscopic guidance. This means you won’t be reporting any RS&I code. For instance, this is how you’d code a lumbar myelography under fluoroscopic guidance only:

• 62284 (Injection procedure for myelography and/or computed tomography, lumbar)
• +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)).

See What Changes When Working Alongside Other Specialties

You’ll find similar situations involving the interventional radiology specialty. While the radiologist may perform the entirety of the procedure, there may not be an all-encompassing code that includes both portions.

Consider a scenario involving the change of an abscess drain catheter. In the operative report, the surgeon documents the injection of contrast into the cavity and subsequent removal and replacement of an abscess drainage catheter under fluoroscopic guidance. Here, you’ve got the provider performing both the surgical and radiological portions of the service, including a formal dictation. You’ll report the following codes:

• 49423 (Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure))
• 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation).

Know When to Separate Radiological, Surgical Services

Lastly, consider a scenario where a radiologist performs an interpretation service alongside a physician of another specialty. You’ll find this scenario play out with surgeries involving a cystourethroscopy and a retrograde pyelogram.

Consider cystourethroscopy code 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service). The code description “exclusive of radiologic service” means that only the surgical component of the pyelogram is included in 52005. Assuming that a radiologist is tasked with interpreting the retrograde pyelogram, you’ll find that this procedure involves two distinct reports. If you’re coding for the radiologist, you won’t have access to the surgical report; however the report for the interpretation of the retrograde pyelogram will look something like the following:

• Fluoroscopy was provided to assist Dr. X. Total fluoroscopy time 18.5 seconds for a calculated dose of 10.11 mGy. Multiple fluoroscopic images were acquired during performance of bilateral retrograde pyelography. The images submitted demonstrate no suspicious filling defects within the opacified renal collecting systems or ureters.

“Most often, the surgeon will perform the retrograde pyelogram, but this radiological interpretation will be performed by a radiologist,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. While the radiologist formally interprets the retrograde pyelography, that doesn’t mean that the urologist performing the service doesn’t utilize the fluoroscopic imaging throughout the course of the surgery. It just means that the surgeon’s utilization of the fluoroscopic imaging (without interpretation) is inclusive of code 52005.

Since the surgical component of the pyelography is included in 52005, you need to know exactly how to submit code 74420 (Urography, retrograde, with or without KUB) for the radiologist’s portion of the service. “The radiologist performing the interpretation will submit 74420 with modifier 26 [Professional Component],” says Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “The urologist should only report 74420 when both performing the pyelography and subsequently interpreting the results,” Della Vella explains.

Coder’s note: The code description in 74420 includes KUB, but does not require documentation of X-rays of the kidneys, ureters, or bladder in order to report it. As you can see in the example radiological interpretation report of the retrograde pyelography above, there is no documentation of X-ray imaging whatsoever. This still qualifies as 74420-26.