Radiology Coding Alert

When radiology coders have to assign CPT Codes for a computed tomography (CT) scan from the diaphragm to the pubis, they sometimes get that sinking feeling but vague orders need not cause a stomach ache. Written guidelines make it look so easy. They'll tell you to use both 74150 (Computerized axial tomography, abdomen; without contrast material), or 74160 ( with contrast material[s]) or CPT 74170 ( without contrast material, followed by contrast material[s] and further section) and 72192 (Computerized axial tomography, pelvis; without contrast material) or 72193 ( with contrast material[s]), or 72194 (... without contrast material, followed by contrast material[s] and further section) when scanning all the way from diaphragm to pubis. Obviously, the codes chosen for the abdominal and pelvic CT scans would need to "match" with regard to the contrast protocol used, i.e., with, without, or without followed by with contrast. Define "Abdomen"and "Pelvis" The American College of Radiology (ACR) provides a standard for these procedures in its Standard for the Performance of Computed Tomography of the Abdomen and Pelvis (for a copy, go to www.acr.org). ACR rules specify 74150 when scanning "upper abdomen" only, and 72192 when scanning the "pelvic area" only. However, in the real world of clinical radiology practice, applying the rule is not so simple. According to the ACR standard, which draws an imaginary line between abdomen and pelvis, the reference points for a CT of the abdomen extend from the top of the diaphragm to the border of the pelvic bone known as the iliac crest. The reference points for a CT of the pelvis are from the iliac crest to the lower end of the pelvic bone (the ischial tuberosity).

On the harder question of when to do both exams, the ACR standard states, "Often, depending on the clinical circumstances, both the abdomen and pelvis must be examined." And that's the problem. The decision depends on the radiologist's evaluation of clinical circumstances, but as Mark McElroy, CPC, a radiology technician at University Health Services in Augusta, Ga., says, "What's intended to be ordered isn't always what's ordered." Coding When Referrals are Vague McElroy agrees that the definitions and guidance in the ACR standard support his department's protocols. However, the radiologist still has to respond to vague indications and exam orders from referring physicians who may not be familiar with or aware of CT standards or protocols. The radiologist also remains responsible for clinical evaluation of indications to decide when abdominal and/or pelvic CT is appropriate.

To understand the importance of indications received from the referring physician, as well as the challenge faced by the radiologist trying to do the right exams as efficiently as possible the first time, consider the following case: [...]