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Radiology Coding Alert

Test Your UGI Coding Savvy

Published on Sat Jan 22, 2005

Use this authentic report to sharpen your 74240 and  74241 skills

Upper gastrointestinal studies can really put you through the wringer, but our radiology coding specialists share the three expert principles that take the fear out of coding KUBs.

Start With the Basics

Study the sample report below, then use our checklist to navigate your way to the right code every time.
 
Dictated Report: Sixty-eight-year-old patient presents with unexplained nausea with vomiting.
 
ESOPHAGUS AND UPPER GI SERIES: The preliminary fluoroscopic spot image shows a normal bowel gas pattern. Swallowing is evaluated with rapid sequence imaging in AP and lateral position. Swallowing appears normal. The esophagus has normal configuration and motility, as well as mucosal pattern. No mass, stricture, or ulceration is seen. The stomach and duodenum have normal configuration and fold patterns. No mass or ulceration is seen. The ligament of Treitz is normally positioned. IMPRESSION: Normal esophagus and upper GI series.
 
Do this: The report indicates radiologic imaging of the upper gastrointestinal (UGI) tract, so it's pretty easy to narrow down your choices to the "Gastrointestinal Tract" subheading of "Diagnostic Radiology" in your CPT manual .
 
And because there is no mention of air contrast, high-density barium, or other extras, you can limit your decision to CPT 74240 (Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB) or 74241 (... with or without delayed films, with KUB).
 
With this in mind, follow the steps below to find out how to choose the right code when a report like this lands on your desk.

Clear Up KUB Confusion
 
KUB is an abbreviation for kidney-ureter-bladder.
 
Myth: All you need to decide if you have a KUB is a report indicating whether or not an x-ray revealed these three structures.
 
Reality: A KUB does NOT require a clear view of the kidneys, ureter, or bladder. Hidden trap: Many payers want you to have an archived image of the majority of the abdomen and pelvis in one projection if you report a KUB.

Spot the Real Problem
 
Knowing whether the words "preliminary fluoroscopic spot image" mean KUB is probably the most confusing issue with this report.
 
What really matters is how much coverage the image provides. Many contemporary fluoroscopic machines allow you to do a wide field of view, and your physician may have chosen this equipment for his preliminary views. Some physicians refer to this as a spot film - despite its large views - because it isn't done with overhead equipment.
 
Use the following guidelines to determine if your spot image is a KUB.
 
1. Expansive Spot Image Is a KUB
 
A KUB for 74241 is a general x-ray of the mid-abdominal and pelvic region, says Stacy Gregory, RCC, CPC, charge capture and reconciliation specialist with Franciscan Health System's Imaging Support Services in Tacoma, Wash. She says that the description does not specify overhead film, fluoroscopically guided spot film, or whether you get the image by an analog or digital technique.
 
Gregory emphasizes that you need to understand the context in which you may consider a spot film a KUB. A preliminary fluoro spot film of the esophagus, rather than the abdomen, for example, is not a KUB and you should not consider it one for UGI coding, she says. In this case, the film reveals a "normal bowel gas pattern" indicating a focus on the abdomen, she says.
 
Remember: Most payers require the majority of the abdomen and pelvis to be visible in the film. A limited film of the abdomen is not sufficient.
 
Gregory recalls radiologists and coding trainers alike who agree that the preliminary spot film, sometimes called an abdominal spot film, is a KUB in the UGI context.
 
2. Limited Spot Image Fails the KUB Test
 
A KUB may not show a K, a U, nor a B, agrees Cheryl Schad, BA, CPCM, CPC, owner of Schad Medical Management, a medical reimbursement consulting firm in New Jersey. But it does involve taking a full film of the patient rather than a limited one, she says. Alone, this would be coded as 74000 (Radiologic examination, abdomen; single anteroposterior view).
 
Schad contends that a limited or coned down spot film does not equal a KUB because:
 

  •  a limited spot film yields an image of a small anatomic area, and
     
  •  a KUB is a radiographic image that shows a broad view of the abdomen.

    Report the Correct Procedure
     
    If the preliminary spot film reveals:

  •  a wide view of the abdomen and pelvis, report 74241, because this image qualifies as a KUB;
     
  •  a narrow, coned down image, report 74240, because this image does not qualify as a KUB.
     
    Because 74241 pays more than 74240, you need to be positive which procedure was performed or you'll end up reimbursing your payer. Bottom line: You must know what your physician meant when he said spot film. Work with your physician so he understands the importance of proper documentation and the efficiency of simply specifying KUB or limited spot film in his dictation.

    End With ICD-9
     
    In all the frustration of choosing the correct CPT code, don't forget ICD-9. In this case, all you have are signs and symptoms - no unusual findings are reported and no official diagnosis is made.
     
    The patient presented with unexplained nausea with vomiting, so 787.01 (Nausea with vomiting) is your best bet.

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