Radiology Coding Alert

When radiologists perform multiple nuclear medicine bone scans on a patient during the same day, coders must understand which combinations of nuclear medicine bone scan codes may be reported and which modifiers may be appended, especially when SPECT is performed in combination with planar imaging.

Its not unusual for multiple diagnostic scans to be done, points out Deepa Malhotra, MS, CPC, director of coding and compliance for Healthcare Information Services Ltd., in Willowbrook, Ill., which provides billing services to more than 200 physician in the Chicago area. Often, a simple study will be conducted, which identifies an abnormality that will be explored further in a separate session. But in these situations, coders often wonder which codes may be reported together, which are considered component codes of a more extensive study, and which modifiers are most appropriate.

Bone scans will generally be ordered to detect bone malignancies (i.e., 170.1, malignant neoplasm of bone and articular cartilage, mandible) and stress fractures (733.16, pathologic fracture of tibia or fibula), or to differentiate between osteomyelitis (730.21, unspecified osteomyelitis, shoulder region) and cellulitis (682.3, other cellulitis and abscess, upper arm and forearm).

The CPT Codes that prompts most questions is 78320 (bone and/or joint imaging; tomographic [SPECT]). SPECT, which stands for single photon emission computerized tomography, is an imaging technique using radiopharmaceutical and circumferential images, rather than standard planar images to produce three-dimensional images. SPECT has been called nuclear medicines version of 3-D reconstruction, and may be ordered after two-dimensional, or planar, scans have been performed. In addition to 78320, CPT lists four planar scans in the 2001 manual:

78300 bone and/or joint imaging; limited area
78305 ... multiple areas
78306 ... whole body
78315 ... three-phase study

Typically, 78300 is performed on a single body part, like a knee, while 78305 would assess several body parts, such as the hips and upper legs. The whole body, as described in 78306, includes the head to at least the level of the knees. CPT 78315 CPT 78315CPT 78300 and 78305. However, they are not considered mutually exclusive procedures. They are listed in the comprehensive/component section of the CCI edits and carry the CCI modifier indicator of 1, which means that modifier -59 (distinct procedural service) would be appended if billed.

In order to bill these codes with modifier -59, radiology practices must follow the established guidelines for use of this modifier, points out Stacey Hall, RHIT, CPC, CCS-P, director of corporate coding for Medical Management Professionals Inc., a national billing and management firm for hospital-based practices in Chattanooga, Tenn. According to the AMAs general correct coding practices guidelines, modifier -59 would be appended when the scans represent a different session or patient encounter, different site or organ system, or separate lesion or separate injury not ordinarily encountered or performed on the same day by the same physician.

Reporting Combinations of Planar Bone Scans

Code 78315 describes the triple-phase bone scan, which assesses vascular flow, blood pool images and delayed static images. Code 78315 may also be reported in combination with the other three planar bone scan codes, Malhotra says. But when this occurs, 78300, 78305 and 78306 would carry modifier -59. However, because 78315 includes static images, the other codes would be reported separately only if performed during a separate session. Codes 78300 or 78305, however, are never payable in combination with 78306.

At play in this instance, Malhotra says, is the concept of most extensive procedure. Its similar to climbing a ladder. To get to the fifth step of the ladder, you have to go through steps one, two, three and four. Its the same way with these codes. The whole body scan represents that fifth step, and its understood that any individual body parts scanned are components of the whole.

However, its possible in other instances that a simpler procedure leads to a comprehensive procedure. If the radiologist interprets a limited scan and sees something that indicates further investigation, SPECT imaging might occur later in the same day. In this instance, its as if you climbed the first step of the ladder, went back down, and then later climbed all the way to the fifth step. In this instance, you could report the limited scan (78300) and report the SPECT imaging (78320) as being conducted at a later session. modifier -59 is the signal that communicates the circumstances that required both studies.

Circumstances that justify reporting these codes in combination with one another must adhere to coding guidelines, be medically necessary, and fully documented in the patient record, Hall notes.

Note: Many coding experts consider modifier -59 a modifier of last resort because it can easily trigger a payer audit. Practices will always be paid with the -59 because it bypasses payer rebundling edits. Therefore, payers audit claims with modifier -59 more frequently to ensure that documentation supports the separate nature of the services and not just to maximize reimbursement.