Radiology Coding Alert

Question: If our radiologist performs direct axial and coronal imaging on a CT examination, can we report 76375 ? For example, we've got a report for a CT of the orbit, sella, or posterior fossa, etc., (70480). Can we consider 76375 a "routine" addition to 70480, or do we have to have written orders?

Oregon Subscriber

Answer: The word you need to focus on is "direct." If the documentation shows that the radiologist obtained the images directly, you can't use reformatting code 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of  computed tomography, magnetic resonance imaging, or other tomographic modality).
 
In the scenario you describe, you correctly choose code 70480 (Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material). The CPT instructions include a note to consult 76375 if your radiologist performs 70480 with coronal, sagittal, and/or oblique sections; you must include 76375.
 
Key: Code 76375 is about reconstruction; it's not about direct imaging. Don't use this code if the patient simply changes position to image another plane or to rescan to get the sagittals, coronals, or other views.
 
Disaster averted: Medicare and the OIG take the proper use of code 76375 very seriously. If your referring provider doesn't include a direct order for 76375, don't report it. The American College of Radiology disputes this requirement, but unless you want to risk costing your practice huge fines, take the cautious route until you see an official decision from the government.