Radiology Coding Alert

Discover whats missing from 78584 and 78585, and fill in the blank correctly.

Nuclear medicine documentation is notorious for using terms you wont find neatly matching CPT descriptors. But help is at hand.

Last month, Solve Your Lung Scan Coding Woes With Real-World Term Tips covered terms you may see for perfusion (78580), aerosol ventilation (78586, 78587),and gaseous ventilation (78591-78594). Now you can apply those skills to identifying the proper code when the physician performs a combined perfusion and ventilation exam, as well as identifying the most likely ICD-9 and HCPCS codes for these services.

Avoid This Common Combo-Study Pitfall

Nuclear radiologists may perform both perfusion and ventilation studies at the same encounter.

In this case, you should not report a perfusion code and a separate ventilation code. Instead, you should choose from three combination codes:

" 78584 -- Pulmonary perfusion imaging, particulate,with ventilation; single breath

" 78585 -- & rebreathing and washout, with or without single breath

" 78588 -- Pulmonary perfusion imaging, particulate,with ventilation imaging, aerosol, 1 or multiple projections.

Tricky: Code 78588 specifies aerosol, but 78584 and 78585 say ventilation without specifying aerosol or gaseous.

What to do: Consider 78584 and 78585 specific to gaseous studies with perfusion, says Becki Garaud, CPC,CPC-E/M, RCC, compliance education and coding trainer for the University of Washington Physicians and Childrens University Medical Group Compliance Program.

AMAs CPT Assistant (March 1999) explains that CPT added 78588 because (aerosol ventilation plus particulate perfusion lung imaging) would be more accurately reported by using a single code, similar to CPTcode 78585 (gaseous ventilation plus particulate perfusion lung imaging). This quote indicates that 78585 (and similarly, 78584) is appropriate for gaseous ventilation with perfusion.

As you do for the gaseous-only codes (78591-78594,Pulmonary ventilation imaging, gaseous &), youll choose between 78584 and 78585 based on single breath alone (78584) or performance of rebreathing and washout (78585).

For 78588 (aerosol), the number of projections wont affect coding because the descriptor indicates the code is appropriate for one or multiple projections.

Quantitative Is Key to 78596

Code 78596 (Pulmonary quantitative differential function [ventilation/perfusion] study) includes perfusion and ventilation, but measures perfusion and aeration percentages in the lungs various lobes. Providers calculate the result by comparing lungs, or dividing each lung into thirds and calculating the percentage of total counts in each region. Physicians usually order the quantitative test to determine how a patient will handle lung removal.

The quantitative study requires computer collection of at least the anterior and posterior view of the scan, with blending of the right versus left lung counts in the two views to give an overall right versus left lung count proportion, according to CPT Assistant (Winter 1990).

Caution: In response to the question of whether you may report 78585 for a Tc99mMAA/Xe-133 study performed with rebreathing and washout in addition to 78596 for a quantitative study, the Society of Nuclear Medicine (SNM) published a response that you should report only 78596 if you are performing quantification on both ventilation and perfusion.

But if quantification is on only the ventilation OR perfusion, then bill 78585 only.

You can find the question and answer online at http://interactive.snm.org/index.cfm?PageID=8382.

Clinical tip: If you want to learn more about the procedures the lung scan codes describe, read the American College of Radiologys Practice Guideline for the Performance of Pulmonary Scintigraphy (www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/nuc_med/pulmonary_scintigraphy.aspx).

Create Your Own Lung Scan Dictionary

Providers often refer to ventilation/perfusion studies as VQ studies, but the two arent technically synonymous,says Bruce W. Hammond, CRA, CNMT, executive vice president of Diagnostic Health Services, which serves more than a dozen states.

VQ: VQ (or V/Q) refers to 78596, Hammond says.On rare occasions, you may see VA/Q used.

V (or VA) refers to ventilation of the alveoli (tiny air sacs) and Q refers to perfusion of the alveoli. The physician divides the V amount by the Q amount to determine the ratio of ventilation to perfusion.

V&P: You may see ventilation and perfusionreferred to as V&P Lung, which is accurate for 78588; this code only applies to perfusion studies performed with radioaerosol ventilation, Hammond says.

The correct code for a perfusion and ventilation with a gas (usually Xenon 133) would be either 78584 or 78585 based on the technique used, Hammond says.

Avoid assumptions: If you see a term such as VQ in a report, search the documentation to be sure youve pegged the correct code for the service performed. The interchangeable use of VP, VQ, V&P, and V/Q to describe nuclear medicine lung imaging studies is as much about regional colloquialisms and training site shorthand as it is about the actual description, Hammond says.

No Definite Dx? Look for Chest Symptoms

Choosing the proper CPT code is only part of the battle. You also need to be sure you choose a diagnosis code the documentation supports.

As noted above, quantitative studies help physicians predict postsurgical outcomes. But conditions the radiologist may diagnose from other lung scans include pulmonary embolism and infarction (415.1x, Acute pulmonary heart disease; pulmonary embolism and infarction), bronchopulmonary sequestration (748.5,Agenesis, hypoplasia, and dysplasia of lung), or pulmonary trauma (such as 861.2x, Injury to heart and lung; lung, without mention of open wound into thorax).

If the radiologist does not document a definitive diagnosis after the scan, you should report the appropriate signs or symptoms code. Physicians may order lung scans for patients presenting with certain chest and breathing difficulties, such as 786.50 (Chest pain, unspecified), 786.05 (Shortness of breath), 786.52 (Painful respiration), or similar symptoms.

Match Scan Type to Most Likely HCPCS

If your practice bears the cost for the radio-pharmaceutical used in the lung scan, be sure you include the appropriate HCPCS code.

For example, for MAA, which youll typically see with perfusion codes, you should report A9540 (Technetium Tc-99m macroaggregated albumin,diagnostic, per study dose, up to 10 millicuries).

For aerosol tests, youll typically report A9567 (Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries).

HCPCS covers the Xenon gas for gaseous studies with A9558 (Xenon Xe-133 gas, diagnostic, per 10 millicuries).