Radiology Coding Alert

Question: Which CPT code(s) should I report for the following? Our freestanding imaging center performs a sinus CT without contrast. These are images and data scans taken to get computerized data so a surgeon can use the information to build a 3D image with the Instatrak for guidance during surgery.-

The radiologist dictates his scan findings and labels them as "CT sinuses w/3D." We have permanent files of the images and can print hard-copy images from the data at any time.

Oregon Subscriber

Answer: You should report the sinus CT with 70486 (Computed tomography, maxillofacial area; without contrast material).

But fight the urge to report 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation) or 76377 (... requiring image postprocessing on an independent workstation).

The AMA's CPT Changes 2006: An Insider's View explains that these codes describe 3D rendering with interpretation. CPT guidelines instruct you that 76376 and 76377 "require concurrent physician supervision of image postprocessing 3D manipulation of volumetric data set and image rendering."

You may use the 3D rendering codes only when your service meets those requirements, and from your description, the radiologist neither supervises the creation of 3D images nor interprets them.