Radiology Coding Alert

Radiopharmaceutical billing depends on site of service.

Providers order pulmonary ventilation and perfusion studies when they suspect an issue with the flow of air or blood through a patient’s lungs or body. While the procedures involve the pulmonary system, the codes fall under the radiology section of the CPT^® code set thanks to the use of imaging equipment and radioactive tracers during the studies.

Radiology Coding Alert has gathered five helpful tips to alleviate any pulmonary ventilation and perfusion imaging coding confusion.

When are Ventilation and Perfusion Scans Necessary?

A provider may order a ventilation scan, perfusion scan, or a combination ventilation-perfusion (V/Q) scan if the patient presents with any of the following symptoms:

• Fast heart rate
• Breathing difficulties
• Chest pain that isn’t related to the heart

The provider may also order lung scans if they suspect:

• Emphysema, chronic obstructive pulmonary disease (COPD), or another lung disease
• Blockages, such as tumors, blood clots, or emboli, in the airways or lungs

“Ventilation and perfusion studies are typically done by radiology in a hospital since it involves radioactive material and advanced scanning equipment,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

During the procedure, the provider administers a radioactive tracer that emits gamma rays, which are picked up by the scanning equipment to create a picture of the patient’s lungs. The provider then reviews the scans and writes their report.

Tip 1: Identify Certain Words to Verify Ventilation Scans

You’ll report 78579 (Pulmonary ventilation imaging (eg, aerosol or gas)) if the provider performs a ventilation scan. A provider performs a ventilation scan to assess the airflow into and out of the patient’s lungs, as well as how the air moves through the bronchi and bronchioles. The tracer is administered through an aerosol or an inert gas, which the patient inhales through a mask while sitting or lying under the scanner.

Documentation clues: Look for terms such as “gases” or “inhalation” to confirm if the physician performed a ventilation study. “Ventilation documentation identifies the gas or aerosol administered (via nebulizer) and airflow is evaluated by imaging,” Pohlig says.

Tip 2: Perfect Your Perfusion Scan Coding

You’ll assign 78580 (Pulmonary perfusion imaging (eg, particulate)) to report a perfusion test performed on a patient. Providers use perfusion tests to judge how the blood flows in the lungs’ vascular structures.

During a perfusion imaging test, the provider injects radioactive albumin into the patient’s vein. As the scanner picks up the radioactive particles, the provider can assess how the blood is flowing through the patient’s veins.

Documentation clues: “Perfusion documentation identifies the injected radiopharmaceutical and the evaluation of blood flow via imaging,” Pohlig says. While reviewing the procedure note, you may uncover references to macroaggregated albumin (MAA), Technetium (TC) MAA, or TC-99m MAA injections.

Tip 3: Code Combination V/Q Scans Correctly

You’ll report 78582 (Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging) for a combination V/Q scan when a radiologist performs the ventilation and perfusion phases during the same encounter. “A V/Q scan can help diagnose a blood clot in the lungs, which is also known as a pulmonary embolism (PE),” says Kristen R. Taylor, CPC, CHC, CHIAP, associate partner of Pinnacle Enterprise Risk Consulting Services. A patient experiencing shortness of breath or a sharp pain when inhaling could indicate PE.

Providers also use V/Q scans to evaluate for pulmonary hypertension (PHTN). PHTN symptoms include chest pressure or pain, fatigue, and dizziness or fainting spells.

Important: Do not append modifier 52 (Reduced services) to 78582 if the provider only performs one phase of the study. In that case, you’ll choose from either 78579 or 78580 to report the appropriate imaging study.

Tip 4: Look for Comparisons to Report Differential Scans

Providers use differential scans to quantitatively measure and compare the patient’s lungs’ ventilation and perfusion with lung pathology where providers find unbalanced airflow or blood flow in the lungs.

You’ll assign 78597 (Quantitative differential pulmonary perfusion, including imaging when performed) to report a comparative lung perfusion study, which uses a radiopharmaceutical to evaluate the blood flow in each lung.

On the other hand, you’ll select 78598 (Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed) when the provider performs a differential perfusion and ventilation study. “Quantitative differential perfusion or perfusion/ventilation studies are typically done when more extensive evaluation is required,” Pohlig adds.

Conditions where more extensive evaluation is required can include:

• Pre-operative evaluation for lung cancer surgery in a patient with severe obstructive pulmonary disease
• Pre- and post-lung transplantation
• Pre- and post-bullectomy (surgical removal of one or more bullae)
• Volume reduction surgery for obstructive pulmonary disease

Tip 5: Report the Radiopharmaceuticals When Necessary

The site of service where the test is performed will factor into whether you or the facility will report the radiopharmaceutical. “For inpatient or outpatient hospital services, the radiopharmaceutical for diagnostic testing is not paid separately. It is packaged into payment for the testing (outpatient) or the diagnosis-related group (inpatient),” Pohlig says. On the other hand, radiopharmaceuticals are paid separately in physician offices and independent diagnostic testing facilities (IDTFs).

Pay attention to the descriptors: Billing the radiopharmaceutical correctly is important if your practice is seeking reimbursement for the material. Carefully reading the code descriptor will aid you in selecting the correct code.

A “per study dose” implies that only one unit will be billed for the procedure.

Example: A patient comes in for a lung ventilation study. The provider administers Tc- diethylenetriamine-pentaacetic acid (DTPA) aerosol via a nebulizer mask.

In this example, you’ll report just one unit of A9567 (Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries) for the Tc-DTPA, as the code descriptor includes “per study dose.”

Simultaneously, you’ll report multiple radiopharmaceutical code units depending on the dose administered during the procedure. Look for “per millicurie (mCi)” wording in the descriptor to determine how many units to report for the study.

Example: A provider injects 20 mCi of Tc-99m MAA for a lung perfusion study.

In this example, you’ll report two units of A9540 (Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries) since one dose of A9540 allows up to 10 mCi.