Radiology Coding Alert

Submit 76080 for radiological assistance.

Drainage catheters can be difficult to report if you neglect the anatomical location of the structure being drained. You also need to clearly define the extent of services for your radiologist — and that’s not the end of the story. Your physician may just interpret the radiological report or may actually perform the entire evaluation. Do not forget to check if your physician injected any contrast agents for the catheter evaluation. 

Here are some practical examples to help you to refine your catheter coding.

Location Does Not Guide Coding For Sinogram

When your physician injects contrast into a sinus tract and obtains films to study the sinus tract, you should submit code 20501 (Injection of sinus tract; diagnostic [sinogram]). The procedure will need your physician to inject a diagnostic agent, such as contrast material, into a sinus tract that connects an abscess in the body to the skin. Your physician may use imaging guidance to visualize the procedure.

What is a sinogram? A sinogram is a special x-ray procedure where your physician tries to visualize an abnormal opening (sinus) in the body, following the injection of x-ray contrast medium into the opening. The procedure helps to identify and locate the extent of inflammation, abscess, cyst, or lesion.

Example 1: You may read that your physician provided radiological assistance for a fistulogram procedure in a patient with a vesicovaginal fistula when the patient also underwent a cystoscopy.

You report code 20501 (Injection of sinus tract; diagnostic [sinogram]) for the diagnostic fistulogram. Additionally, you report 76080 (Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation) if your provider performed the interpretation of the fistulogram and documented his findings in the medical records. 

Note: In this case, the urologist will submit code 52000 (Cystourethroscopy [separate procedure]) for the cystoscopic examination. 

Example 2: You may read that your physician injected contrast into a fistula and it was seen exiting the fistula about 5 cm from the injection site just superficial to the skin. Your physician in this case will document a diagnosis of skin-to-skin fistula. 

You submit codes 20501 and 76080 for this procedure. 

Append Modifier 26 to 76080

Medicare splits 76080 into professional and technical components for reimbursement. If your physician performed this procedure in a facility outside of the office, you cannot claim the technical component of 76080. Append modifier 26 (Professional component) to 76080 when your physician does the procedure in another facility to claim only the professional component.

Note: For code 76080, remember the following:

• Submit code 76080 only if your provider injects the tube and monitors the exam with fluoroscopy. 

• You assign 76080 alone if only films were submitted to your physician for interpretation from a tube injection.

Check Location of Tube for Contrast Injections

To check an existing catheter in an abscess or cyst, your physician may use contrast injections and then obtain radiological images. This approach helps your physician to check the patency and condition of the catheter. For such assessments using contrast injections, you report code 49424 (Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube [separate procedure]). Additionally, you submit code 76080 (Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation) for the radiological supervision and interpretation services that your physician provides. 

Example: You may read that your physician was called in to assess a postoperative subhepatic abscess in a patient who was given a drainage catheter three days ago. The clinical note may indicate that your physician injected the catheter under fluoroscopic guidance and documented the abscess cavity size and absence of any fistula.

You report the injection service using 49424. For the related fluoroscopic guidance and report, you should use code 76080.

Diagnosis codes: The appropriate code for a subhepatic abscess is 567.22 (Peritoneal abscess). The ICD-10-CM code for a subhepatic abscess is the similarly defined K65.1 (Peritoneal abscess).

When your physician does contrast injection of tubes placed in the gastro-intestinal tract, you submit code 49465 (Contrast injection[s] for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy [or other colonic] tube, from a percutaneous approach including image documentation and report). These tubes may include gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tubes. The code 49465 is inclusive of any fluoroscopic imaging guidance that your physician may use.