Radiology Coding Alert

Key: The number of views is not the same as the number of images.

Radiologists use images to examine what is happening inside the patient’s body from their head to their toes. As a coder, you must know when those images need to accompany documentation, so your radiology practice’s claims get paid.

Read on to understand the guidelines behind image recordings for different radiologic procedures.

Understand That Image Recordings Need to Accompany Documentation

In the CPT^® code set, the diagnostic ultrasound (US) subsection guidelines state “All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated.” But does this information apply to US codes where the descriptor doesn’t specify if images are required?

If you receive a radiologist’s report where they performed a transvaginal US coded with 76830 (Ultrasound, transvaginal) or a US of a patient’s spinal canal with 76800 (Ultrasound, spinal canal and contents), then you will still need to permanently record images of the procedure. While the descriptors for each of the example codes do not clearly state, “with image documentation,” as other CPT^® code descriptors do, the use of “all” at the start of the US guidelines instructs that you will need to permanently record images even if the descriptor doesn’t specify the need.

You may also be wondering how permanently recording images applies to guidance codes. In a situation where the radiologist provides guidance for a procedure, such as CPT^® code 76932 (Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation), you’ll still need to permanently record images to supplement the documentation.

Providing Image Guidance Requires Image Documentation

The Radiology Guidelines of the CPT^® manual includes a subsection titled, “Supervision and Interpretation, Imaging Guidance,” which lists the rules for radiology supervision and interpretation (RS&I) and guidance codes. The guidelines indicate that both guidance and RS&I codes require “image documentation in the patient record,” as well as the following:

• Imaging guidance codes – “description of imaging guidance in the procedure report.”
• RS&I codes – “a procedure report or separate imaging report that includes written documentation of interpretive findings of information contained in the images and radiologic supervision of the service.”

But image documentation of a guided procedure does not have to be captured in real-time with the procedure. “Do I have to have the real-time [images] of the needle entering into the structure as I’m doing it or would images of the needle already in place suffice? What I’ve been able to surmise is if there is an image of the needle in the target location, then that would be sufficient to show that you used image guidance,” says Nate Felt, MS, ATC, PTA, CPC, Senior Consultant for Orthopedic Physician Coding at Intermountain Healthcare.

Image recording exceptions: While the radiologic guidelines dictate that all diagnostic US exams require permanently recorded images, you will find exceptions to the rule. A dive into the Diagnostic Ultrasound subsection of the CPT^® code set shows you do not have to permanently record images for codes where the main diagnostic goal is a biometric measure. These codes include 76514 (Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)), 76516 (Ophthalmic biometry by ultrasound echography, A-scan), and 76519 (…; with intraocular lens power calculation).

Additionally, RS&I codes do not apply to the radiation oncology subsection of the CPT^® manual.

Knowing the Number of Views You Need Will Save Your X-ray Claim

Choosing the correct CPT^® code for a radiologic procedure is dependent on the number of views, and in some cases, the types of views. Some providers may think the number of images will suffice in their documentation, but that is incorrect. As the coder, you will need to know the number of views regardless of how many total images are captured to accurately code the procedure.

“CPT^® codes are based on the number of views, not the number of images. The view is a projection — the angle at which they’re looking at a certain body part. [The radiologist] may take many images of the same view, which is important to keep in mind, if the code is based on the number of views,” says Jennifer Bash, RHIA, RCCIR, CIRCC, CPC, RCC, Director of Coding Education for Advocate Revenue Cycle Management. This means that if the radiologist captures several images of a specific view, then you can count the view once for coding purposes.

Scenario: A 65-year-old male patient arrives at your radiology practice for X-rays of his right ribs. He recently fell on the stairs in his home and is experiencing sharp pain when breathing deeply. The radiologist captures right posterior oblique (RPO), lateral, anteroposterior (AP), and posteroanterior (PA) including the chest views of the patient. The patient sneezed during the capture of the lateral view, which resulted in the radiologist capturing additional images when the patient finished sneezing. The impression of the procedure indicated a fracture of two of the right ribs.

This scenario is a perfect example of how you need to know the number of and type of views. You’ll notice the radiologist captured four distinct views — lateral, RPO, AP, and PA — and the last view also included the patient’s chest. With this information, you’ll use code 71111 (Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views) to report the X-rays. The descriptor for this code mentions a minimum of four views and the PA chest view, which are all documented in the scenario. Plus, even though the radiologist did have to capture multiple images of the lateral view due to the patient’s sneezing, you can only count the view once. You’d also use S22.41XA (Multiple fractures of ribs, right side, initial encounter for closed fracture) to code the diagnosis.