Radiology Coding Alert

Radiology coders often find themselves debating whether a particular imaging study is best described as a limited or complete procedure. Obviously, the answer has a tremendous impact on reimbursement.

There are so many gray areas when performing diagnostic exams like ultrasounds or CTs [computerized tomography], points out Michelle Juette, CPC, business services manager for Yakima Valley Radiology in Yakima, Wash. Its sometimes hard for coders to determine whether the imaging being done can truly be reported as a complete study or simply as a limited study.

For example, during a complete abdominal ultrasound (CPT 76700 , echography, abdominal, B-scan and/or real time with image documentation; complete), the technologist also views both kidneys, which are typically considered retroperitoneal organs. Should the practice bill for a limited retroperitoneal study (CPT 76775 , echography, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; limited) in addition to the complete abdominal study? Or are the kidneys considered to be included in the abdominal study?

In another example, a physician, suspecting appendicitis (540.1, acute appendicitis with peritoneal abscess), orders a focused abdominal ultrasound study of the right lower quadrant (76705, echography, abdominal, B-scan and/or real time with image documentation; limited). The radiologist finds diffuse peritoneal fluid and extends the examination to include the remainder of the abdomen. Can the practice code and bill only for the limited exam as ordered? Or may it report a complete abdominal study?

Professional radiology coders like Juette recommend the following three strategies to help bring these issues into better focus and code more accurately:

Strategy 1: Gain a clear understanding of the clinical definitions for each anatomical area studied. Several specific anatomical areas generate the majority of questions in the complete vs. limited study debate. These include the abdominal, retroperitoneal, nonobstetrical pelvic and obstetrical pelvic studies. There is a certain amount of overlap between some of these areas, where specific organs may fall into both areas, says Patti Offner, RT, with Diagnostic Imaging Inc. in Philadelphia. That creates a lot of confusion. For instance, the abdominal and retroperitoneal studies may view some of the same organs.

Both Offner and Juette say they rely heavily on definitions provided by the American College of Radiology (ACR) in its Ultrasound Coding Users Guide. These descriptions should be the starting point for any coder, explains Juette. They give a thorough description of what organs and systems are included in specific anatomical studies.

The ACR defines a complete retroperitoneal ultrasound (76770), for instance, as including images of the aorta, inferior vena cava, retroperitoneal structures and the retroperitoneal lymph nodes. The code also can include examination of urinary tract organs like the kidneys, ureter and bladder because these organs are retroperitoneal for the most part.

Similarly, the ACR defines an abdominal study (76700) as extending from the diaphragm to the level of the umbilicus, and includes images of the liver, spleen, gallbladder, common duct, pancreas and hollow upper abdominal viscera. ACR notes, however, that 76700 may also include incidental examination of each kidney, the inferior vena cava and the upper abdominal aorta.

Although some organs are mentioned in both definitions, both Offner and Juette note that the primary focus of the exam determines which is coded. A detailed evaluation of the inferior vena cava, for instance, most likely would be billed with the limited retroperitoneal code, even though it is also mentioned in the description for an abdominal ultrasound.

Likewise, organs that are incidentally viewed during a focused study of adjoining anatomy usually are not coded separately. When we are doing CTs of the abdomen [e.g., 74160, computerized axial tomography, abdomen, with contrast material(s)], we may take a few extra slices below the umbilicus to get a better sense of whats going on, says Juette. Usually, though, this doesnt constitute an additional study of the pelvic region [72193, computerized axial tomography, pelvis; with contrast material(s)].

Consequently, the views of the kidneys in the first example would be included in a complete abdominal study and should not be coded with an additional limited retroperitoneal study.

Strategy 2: Work closely with local carriers to determine preferred coding. Many Medicare payers have adopted boilerplate language to describe limited and complete studies for each anatomical area although most coders say this does little to clarify what constitutes a limited study. For instance, the carriers in Iowa, Virginia and New Jersey share similar definitions for non-obstetrical pelvic ultrasounds (76856, echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete; and 76857, limited or follow up [e.g., for follicles]):

Complete A complete study visualizes all of the structures or organs within the anatomic description of that study (generally within the pelvic rim and below the umbilicus) and includes a written interpretation.

Limited A limited study includes only a single quadrant or a single diagnostic problem (e.g., unilateral ovarian disease). A follow-up study is used to re-evaluate a problem after an initial study and interpretation to clarify a finding or to ascertain response to treatment.

Juette notes that although these descriptions appear to be clear, coders may be confused if more than a single quadrant or organ system is viewed, but the entire anatomical region isnt studied. Sometimes, she says, carriers will allow a complete study to be billed in such cases, but others may require coders to report several limited studies in a given anatomical region.

Ive found that there is no single answer when these issues come up and that there is no agreement among carriers or coders. It is vital that coders communicate with carriers when a questionable situation arises, Juette adds.

Strategy 3: Communicate with the ordering physician. Juette points out that when determining whether a study is complete or limited, coders also should refer to the radiology order. If only a limited ultrasound was ordered and performed, then that is what should be billed.

There are times, however, when a radiologist sees something during the study and will want to take additional views or studies. For instance, a physician may order a limited abdominal ultrasound for a patient experiencing pain in the right upper quadrant. The radiologist sees signs of gallbladder disease (575.0, acute cholecystitis), accompanied by an abscess with fluid flowing into the abdomen. He or she then expands the ultrasound to determine if the patient is suffering from diffuse peritonitis (567.0). This case is similar to the second example above concerning a limited study for the question of appendicitis that was expanded on the basis of the ultrasound and clinical findings.

In cases like these, the radiology practice should proceed carefully, says Gary Dorfman, MD, FACR, FSCVIR, president of Health Care Value Systems in North Kingstown, Pa., which provides practice management services and revenue optimization techniques through coding and billing support. It is good medicine for a radiology practice to expand the study to determine what is causing the patients symptoms, he says. Coding and billing this additional effort from the payers perspective, however, is not so clear-cut.

Radiology practices particularly office-based or independent diagnostic testing facilities must consider the Stark Law that deals with self referral. Most radiology experts note that these rules affect only additional studies, not simply expanding a limited study to a complete study. Because this has not been documented in writing, however, Dorfman recommends a more cautious approach, especially when dealing with Medicare.

It is prudent for radiology practices to contact referring physicians to inform them of the need to go beyond the original order. Then, the report should document the extent of the examination, the contact with the referring physician and, in the case of a complete examination, the medical reason for extending the study, he advises. If the referring physician is unavailable, the medically indicated study should still be performed and billed. But the providing physician should still document the medical decision-making that occurred to justify the change in examination to support the billing. The practice should be prepared to defend its billing with thorough documentation.