Radiology Coding Alert

Comply with these PET, bone imaging, and vertebroplasty rules, too.

You may find answers to your coding questions in an often overlooked place: the NCCI Policy Manual for Medicare Services. This manual for Medicare's National Correct Coding Initiative (aka NCCI or CCI) includes information on both general CCI concepts and explanations of code-specific edits.

Try your hand at four questions, and then learn where to look in the manual to support your coding choices.

1. Examine Chest Tube X-Ray Options

Scenario: The radiologist performs a pleural tap and places a chest tube. He then interprets the X-ray taken to confirm the tube's position. You should report:

A. 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure])

B. 32422, 71020 (Radiologic examination, chest, 2 views, frontal and lateral)

C. 32422, 71020-26 (Professional component)

D. 32422, 71020-26-59 (Distinct procedural service)

Solution: A. You should report only 32422. The CCI manual addresses this issue in Chapter V, Section C.14, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner of Precision Auditing and Coding.

In Chapter IX, Section C.9, the manual explains that the X-ray isn't separately reportable because it is integral to the procedure. Providers typically perform an X-ray to check placement.

Keep in mind: If the radiologist performs a chest X-ray to diagnose the effusion or other medical issue that then leads to the decision to perform the chest tube service, that diagnostic X-ray is separately reportable. You also may report imaging guidance in addition to 32422, such as ultrasound guidance code 76942 (Ultrasonic guidance for needle placement ...).

The record should "mention the US guidance and document the necessary details of visualization," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania Department of Medicine in Philadelphia.

2. Pick Coding for Pre-PET Finger Stick

Scenario: Your patient requires a finger stick blood glucose test prior to a PET scan. Should you report the blood glucose test in addition to the PET scan?

A. Yes

B. No

Solution: B. No, you should not report the blood glucose test separately. You'll find this in Chapter IX, Section E.7, says Stumpf.

The CCI manual states that "CPT codes 82948 (glucose; blood, reagent strip) or 82962 (glucose, blood by glucose monitoring device(s)...) should not be reported separately for the measurement of the finger stick blood glucose included in a PET procedure."

3. Investigate Initial Vascular Flow Imaging

Scenario: The physician documented vascular flow imaging with three phase bone imaging. You should report:

A. 78315 (Bone and/or joint imaging; 3 phase study).

B. 78445 (Non-cardiac vascular flow imaging [i.e., angiography, venography]).

C. 78315, 78445.

D. 78315, 78445-59.

Solution: A. You should report only the bone imaging. Medicare includes initial vascular flow imaging in 78315, the manual states. You'll find this in Chapter IX, Section E.10, says Stumpf.

If you're ever tempted to report 78445, CCI edits will ensure a denial. CCI's edit for these codes has a modifier indicator of 0, meaning that you may not use a modifier to override the edit.

4. Assess Need for Vertebroplasty Add-On Code

Scenario: The physician performs percutaneous vertebroplasty on contiguous vertebral bodies T12 and L1. The most appropriate choice among the following options is:

A. 22520 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; thoracic)

B. 22521 (... lumbar)

C. 22520, 22521

D. 22520, +22522 (... each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure])

Solution: D. Look in Chapter VIII, Section C.20 of the manual for this information, says Stumpf.

The tricky issue with this scenario is that the physician performs services in both the thoracic and lumbar areas, but you should not report a primary code for each level. "If treatments are performed at both thoracic and lumbar locations, only choose one as the primary site (typically thoracic which is valued higher) and the remaining levels as add-on code +22522 for the additional thoracic and/or lumbar levels treated," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

The CCI manual explains that the add-on code isn't specific to a spinal level, so you "should report only one primary code within the family of codes for one level and should report additional contiguous levels utilizing the add-on code(s) in the family of codes."

Don't forget: Report the radiological supervision and interpretation, such as 72291 (Radiological supervision and interpretation, percutaneous vertebroplasty ...) with modifier 26 appended to indicate professional fee only.

Resource: CCI coding guidelines are created for Medicare, but other payers may follow them. Alternatively, CPT® or other payers may have different directives or rules for you to follow, so always verify guidelines before submitting your claim. Find the complete CCI Manual online at www.cms.gov/NationalCorrectCodInitEd/01_overview.asp.