Radiology Coding Alert

Ignore phases and look for additional procedures, if any.

Your radiologist may supervise the placement or revision of shunts or may actually provide the service. Make sure you know how to report these services and earn your deserved payment. All you have to do is know what steps you can report.

Review These Shuntogram Basics

Defined: A radiographic shuntogram is a simple procedure used to evaluate the function and patency of a ventriculoperitoneal, ventriculoatrial shunt, or an infusion pump. Through this procedure, your radiologist will detect a valve malfunction, ventricular or distal catheter obstruction, peritoneal encystment. “A shuntogram is an exam used to evaluate a potential malfunctioning nonvascular shunt,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA.

During this procedure, your radiologist monitors the clearing from the shunt to infusion tubing. “Contrast material is placed into the valve of a shunt system and the flow is followed for appropriate clearing of contrast agent from the shunt tubing,” says Laureen Jandroep, CPC, CPC-H, CPC-I, CMSCS, CHCI, CEO Certification Coaching Organization, LLC CodingCertification.Org, Egg Harbor City, NJ. A radioactive isotope is introduced in the shunt reservoir and the physician then measures the speed with which it travels to the tubing. In case of a ventricuoperitoneal shunt, this tubing may open into the abdomen.

Learn With This Example

Your radiologist may interpret the delayed movement of the isotope as a problem in the shunt and may decide on an intervention based upon the interpretation.

A typical procedure note may read as follows:

“The patient was first placed in supine position for around 20 minutes. The scalp was shaved over the reservoir and this area was then prepared and draped with aseptic precautions. The shunt reservoir was punctured with a 25-gauge needle to gently inject and 1 mCi 99mTc-DTPA in a volume of 0.1 to 0.5 ml. During the injection procedure, manual transcutaneous pressure was applied to compress the valve to demonstrate ventricular reflux. Sequential pictures of the flowing fluid were obtained with a gamma scintillation camera.”

You should report 75809 (Shuntogram for investigation of previously placed indwelling nonvascular shunt [e.g., Leveen shunt, ventriculoperitoneal shunt, indwelling infusion pump], radiological supervision and interpretation) for the procedure’s supervision and interpretation.

Do Not Count Phases and Positions

Your radiologist may then acquire data in two phases when doing a shuntogram for a ventriculoperitoneal shunt. The first phase may be a dynamic acquisition of one frame every other second. Next will be serial static views of 60 sec every 5 min over the skull, neck and thoraco-abdominal regions for up to 20 min or later if necessary. You report only one unit of 75809 for the whole shuntogram.

If your radiologist does not observe migration for about 30 min in supine position, you may read that the patient was rescanned in a sitting position. If your radiologist fails to detect any migration still, then he/she may pump the valve and try to assess the shunt patency under the camera. You may also read that your radiologist attempted to draw a clearance curve and calculate the clearance half-time of the reservoir. Once again, all these maneuvers do not affect your reporting.

Check for Other Procedure Codes

Make sure you are not missing any other procedures that your physician does. For example, your physician may be doing a shuntogram for a ventriculoperitoneal shunt tap. “The purpose of shunt taps varies from CSF analysis to rule out infection, intracranial pressure measurement to rule out hydrocephalus, and observation of flow to rule out shunt obstruction,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

When reporting a shunt tap, you submit code 61070 (Puncture of shunt tubing or reservoir for aspiration or injection procedure). You should also report 75809 for the procedure’s supervision and interpretation. “It is worth noting that CMS has stated that CPT® 75809 does not limit the supervision and interpretation code to one particular modality. Regardless of fluoroscopic and/or ultrasonic guidance utilized, you only report 75809,” says Hembree. “Remember to append -26 modifier for the professional service alone if your physician does not own the radiological equipment needed for imaging the flow,” says Przybylski.

Let the following scenario and procedure note documentation guide your coding:

Example: You may read that the patient was positioned supine while your physician located the ventriculoperitoneal shunt reservoir as a smooth dome under the skin on the right side of the head. Your physician may then clean the skin with an antiseptic and apply a fenestrated drape over the area of the shunt. The operative note details indicate the following:

“A small 23-gauge butterfly needle was inserted perpendicular to the skin into the reservoir. Soon after entry, a drop in resistance was felt. The needle was then advanced slowly until the bevel of the needle was fully inside the reservoir. The needle was then held securely to allow the cerebrospinal fluid to enter the tubing. The flow was poor initially and the angle of the needle was adjusted to facilitate the flow.”

“Anticipating a proximal shunt obstruction, the depth of the needle was adjusted to collect the sample. The opening pressure was measured using a manometer. Around 5 ml of cerebrospinal fluid was slowly collected in 4 separate containers to be sent for analysis for cell count, protein level, glucose level, Gram stain, and culture. The needle was then withdrawn from the reservoir and pressure was gently applied for 2 minutes over the entry site with gauze.”

Interpretation: In this case, you can confirm from the note that your surgeon performed a puncture of the shunt reservoir to collect fluid for analysis. You report this with code 61070 and 75809.

Remember these two tips when reporting 61070:

1. You can report 61070 regardless of whether your surgeon approaches the shunt tubing or the reservoir.
2. You can report 61070 regardless of whether your surgeon attempts an aspiration or injection of the shunt.

Your physician may inject contrast material to evaluate a shunt that is in place and may then follow the flow of the contrast under radiological supervision. In this case, you will report code 49427 (Injection procedure [e.g., contrast media] for evaluation of previously placed peritoneal-venous shunt) for the injection of the contrast and 75809 for the radiological supervision.

Note: You may read that your physician injected a radiotracer, such as TC99m-SC or TC99m-MAA, into the left lower quadrant of the abdomen of a patient who had a LeVeen shunt. Your physician may then massage to distribute the radiotracer and then obtain radiographs to evaluate patency of the peritoneal venous shunt. In this case, you turn to a more specific code for peritoneal-venous shunt, 78291 (Peritoneal-venous shunt patency test [eg, for LeVeen, Denver shunt]) and 49427. “CPT® code 75809 should be reported for supervision and interpretation of shunt procedures unless radioactive contrast material is used for a peritoneal-venous shunt, in which you would then report CPT® code 78291,” says Hembree.

Caution: You need to be specific about what your radiologist did. Do not confuse codes 49427 and 61070. “Code 49427 involves contrast injected into peritoneal cavity and code 61070 is for puncture into tubing or reservoir,” says Jandroep. “You can bill 75809 with 61070 and 49427.”

Assign X-Ray Codes for Non-Contrast Shunt

You have no single code for a non-contrast shunt series. You report such shunt series with the X-ray codes for individual body areas. “If a non-contrast study is performed using x-rays only than you would report the corresponding x-ray codes instead of the radiological shuntogram code,” says Hembree.

Example: For non-shunt series with antero-posterior and lateral views of the skull, you report code 70250 (Radiologic examination, skull; less than 4 views) and for that in the neck you report code 70360 (Radiologic examination; neck, soft tissue).