Radiology Coding Alert

Unlisted-procedure code 76497 or 78499 could be your key to reimbursement

Carriers and coders go back and forth on how to code for CT coronary calcium scoring but our experts put an end to this debate and reveal why unlisted-procedure codes are your best bet.

Hone Your CT Coding With These Tips

Reality: Radiology is constantly developing new technology and procedures - such as CT coronary calcium scoring - and codes for these new services may not be ready when you need them. 
 
Radiologists use computed tomography (for example electron beam or ultrafast cardiac gated CT) to determine how much calcium is present in coronary arteries and the resulting score helps them keep track of the patient's risk for coronary artery disease.
 
"There is currently no specific CPT or HCPCS code which accurately represents this study " says Stacy M. Gregory RCC CPC an Imaging Support Services Charge Capture/Reconciliation Specialist with Franciscan Health System in Tacoma Wash. 
 
Way out: An unlisted-procedure code can be your best friend when coding coronary calcium scoring sometimes referred to as ultrafast or cardiac scoring. Code 76497 (Unlisted computed tomography procedure [e.g. diagnostic interventional]) provides one solution to the coronary calcium scoring problem Gregory says. 
 
Another possibility is 78499 (Unlisted cardiovascular procedure diagnostic nuclear medicine) which is often listed for this procedure in payer policies says Cindy C. Parman CPC CPC-H RCC President-Elect AAPC National Advisory Board and co-owner of Coding Strategies Inc. in Powder Springs Ga. If you are sure your carrier will deny your claim it won't make a difference which unlisted-procedure code you report (78499 or 76497) Parman adds. "Both will be individually reviewed by the insurance company."
 
Time-saver: Because coronary calcium scoring uses computed tomography the carrier may prefer that you don't report an unlisted-procedure code that references diagnostic nuclear medicine. Ask the payer to let you know in writing - before you submit the claim - whether the company prefers 76497 or 78499.   
 
Myth: Gregory has found that "it is a common misconception that CPT 71275 [Computed tomographic angiography chest without contrast material(s) followed by contrast material(s) and further sections including image postprocessing] is an acceptable code for billing CT [coronary calcium] scoring." Code 71275 is not appropriate for this service which is generally performed as a screening study. Gregory says that to charge for 71275 the radiologist must perform a CTA "including pre- and postcontrast images further sections and image postprocessing (3D multiplanar reconstructions)."
 
Some coders choose 71250 (Computed tomography thorax; without contrast material) and then append modifier -52 (Reduced services) to reflect the procedure's limited CT of the thorax. Because 71250 does not precisely describe coronary calcium scoring however many carriers prefer unlisted-procedure codes. 
 
The American Medical Association requires you to report an unlisted-procedure code for services not precisely described by another code Gregory says. Unlisted-procedure codes exist specifically for situations in which a physician performs a service or procedure that does not have a particular CPT code.

Don't Assume Denial

The bottom line: "Most insurance plans do not cover this elective screening procedure " Gregory says. "The typically accepted way of billing for these is to collect payment in full from the patient at the time of the appointment." Gregory finds that patients pay between $200 and $400 depending on their geographic location. Generally the test is not billed to the patient's insurance but some offices have managed to get reimbursed after calling the private insurance company and getting its written agreement to pay.
 
Medicare also does not cover this procedure Parman says. She suggests that you advise the patient in advance that Medicare will not pay for electron beam computed tomography ultrafast cardiac CT scan or coronary calcium scoring.
 
ABN advice: Parman says Medicare patients need to sign an advance beneficiary notice (ABN) prior to a service or procedure that is sometimes covered but may be rejected due to the patient's individual condition. You don't need an ABN if a service like cardiac scoring is never covered by Medicare. Regardless Parman believes "it is good business practice to advise the patient of the lack of coverage." And a signed ABN is excellent documentation that the discussion occurred.
 
Most important: Because there is the slim chance for reimbursement from private insurers make sure you know how carriers want you to code CT coronary calcium scoring. You can expect 76380 (Computed tomography limited or localized follow-up study) 76499 (Unlisted diagnostic radiographic procedure) and even HCPCS S8092 (Electron beam computed tomography [also known as ultrafast CT cine CT]). Be sure you ask for specific written guidance to increase the likelihood you'll be compensated for this CT procedure.