Radiology Coding Alert

Use this case study as an example to drive the point home.

Most coders will attest that it’s not usually the services you code in high frequency that tend to be the most problematic. Rather, it’s those services that you encounter enough to be familiar with, but not enough to consider a part of your coding wheelhouse that tend to cause the most headaches.

Thyroid imaging studies often fall in to that latter category — which is why you’ve got to arm yourself with some pertinent bits of knowledge to get the coding mechanics down pat. That point rings especially true when it comes to discerning between a few key thyroid studies that, on the surface, might not seem too dissimilar.

Walk yourself through this clinical scenario to break down some of the crucial differences between three distinct thyroid imaging studies.

Pinpoint Key Details Within Dictation Report

Scenario: The exam header indicates a thyroid ultrasound (US) study. Documentation states the following: “Color flow images were obtained. Longitudinal images of the thyroid gland are obtained. Axial imagines are obtained through the superior, mid, and inferior aspects thyroid gland, on the left and right. Images of the thyroid isthmus were acquired.” The findings and impression discuss the characteristics of three thyroid nodules, but don’t mention vascular flow.

Question: Does this meet the criteria for 78013 or should you report codes 76536 and 93380?

This is a tricky example because the technique does indicate that color flow Doppler images were obtained. A Doppler US examines cardiovascular blood flow, but you’ll need much more documentation than what’s included in the technique of the report to code the exam as such. In order to meet the criteria for a Doppler exam, you’d need documentation of both color flow and spectral analysis (i.e. waveform analysis, velocity, spectral Doppler, acceleration rate, etc.).

However, even with the proper documentation, you still don’t have enough to justify reporting code 93880 (Duplex scan of extracranial arteries; complete bilateral study). Code 93880 must include an evaluation of the common, internal, and external carotid arteries. Documentation must also include the vertebral arteries. This exam is typically performed for specific diagnostic reasons and does not go hand-in-hand with a soft tissue thyroid US, such as 76536 (Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation). This is further indicated by the National Correct Coding Initiative (NCCI) edit between 76856 and 93880, showing a modifier indicator of “1.” While this does allow for appending modifier 59 or X{EPSU} to the column 2 code (93880), you’d need documentation to support code 93880 in addition to clear diagnostic reasoning for performing the two procedures together. Performing vascular imaging of the thyroid arteries would typically not require complete imaging of the extracranial arteries included in code 93880.

Consider Criteria for 78013 Reporting

You also need to be especially cautious in determining when it’s appropriate to report code 78013 (Thyroid imaging (including vascular flow, when performed)). The code description is lacking in specificity, but that doesn’t mean that this code meets the criteria for any thyroid imaging that includes vascular flow. In order to report code 78013, you first want to identify that report includes documentation of an intravenous injection of a radiopharmaceutical contrast substance. Furthermore, this code isn’t reported for routine US imagining as indicated in the example. Instead, code 78013 is reported for nuclear medicine imaging that involves an injection of contrast and subsequent imaging taken with a gamma camera.

Know this: Intravenous injection of a radiopharmaceutical as indicated in code 78013 is different than the “thyroid uptake” included in code 78012 (Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)). “This service involves the patient taking an oral dose of radioactive iodine,” details Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “Imaging using a gamma probe is then performed approximately 24 hours later,” Rosenberg adds. When the patient receives both thyroid uptake measurements and the thyroid scan as indicated in coded 78013, you will report code 78014 (… with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)).

Traditional US imaging of the thyroid, by definition, will only include imaging of the soft tissue component of the head and neck. This is further identified in the example based on the documentation that’s exclusive to the three identified thyroid nodules. Since the documentation clearly doesn’t support a code from range 78012-78014, nor does it meet the criteria for 78330 reporting, your only option is to code the service with 76856.