Radiology Coding Alert

In 2002, CPT Codes approved three new codes for radiofrequency ablation (RFA) of the liver - 47370, 47380, 47382. When employing these new procedural codes, radiology coders should understand that they can't use an RFA code more than once per operative session, even if the RFA has removed more than one tumor.

In many primary and metastatic liver cancer cases, certain individual tumors cannot be surgically removed for various reasons including tumor location and/or multiplicity, residual hepatic function, and patient operative risk factors. RFA destroys metastatic tumors quickly and effectively - without surgery. And there's one more reason to celebrate: Medicare and many other payers now reimburse for RFA.

RFA destroys soft tissue cells through heat derived from radiofrequency energy generated by an alternating electrical current. It's just like "cooking the lesion," says Jeff Fulkerson, BA, CPC, coding specialist at the Emory Clinic in Atlanta.

Code Preprocedure E/M Separately

Don't lose sight of the fact that when using the RFA codes, you can use a separate E/M code to bill for the visit that leads to the RFA. Suppose a patient presented with two separate liver lesions measuring 2 cm x 2 cm and 4 cm x 4 cm. Because the lesions' locations precluded surgery, the patient's oncologist referred him to an interventionalist for evaluation. The interventionalist recommended RFA as the most amenable treatment. In this case, you would code the evaluation separately using the E/M level most appropriate to describe the history, physical examination, review of medical records and images, and medical decision-making.

47382 Most Commonly Used RFA Code

Although CPT 2002 contains three new procedural RFA codes (open, laparoscopic and percutaneous), interventionalists will primarily use the percutaneous variant, 47382 (Ablation, one or more liver tumor[s], percutaneous, radiofrequency), Fulkerson says.

The number of ablative passes depends on the number and size of the tumors treated. The procedure usually lasts between 30 minutes and two hours, and the patient typically goes home the same day. Should hospitalization be needed, the admitting physician (typically the interventionalist) may code further E/M services.

The most important thing to understand about 47382, Fulkerson emphasizes, is that the ablation covers one or more tumors during the same operative session. "No matter how many tumors the physician has to treat during that operative session, and no matter how long the procedure lasted, you may submit CPT 47382 only once." If the patient needs to return for serial treatments on more than one date of service, coders may use the code again for those additional treatment sessions.

RFA can also be performed during an abdominal operation or by using a laparoscopic approach, for which codes 47380 (Ablation, open, of one or more liver tumor[s]; radiofrequency) and 47370 (Laparoscopy, surgical, ablation of one or more liver tumor[s]; radiofre-quency) are employed. As with 47382, you may use these codes only once per operative session.

How to Code for Imaging and Guidance

For imaging guidance and monitoring, CPT directs the physician performing the imaging service to use code 76362 (Computerized axial tomographic guidance for, and monitoring of, tissue ablation), 76394 (Magnetic resonance guidance for, and monitoring of, tissue ablation) or 76490 (Ultrasound guidance for, and monitoring of, tissue ablation), depending on the guidance method. Either the surgeon or the radiologist may report the procedural and the guidance codes, based on the manner in which the service is provided - so don't get thrown when you see these codes reported from multiple sources.

As with the RFA code, report just one guidance code per session and modality used, no matter how many tumors are treated, Fulkerson cautions. The only possible exception might occur in a case when a surgeon is removing metastases from a patient's spleen or other body area. During the surgery, he may call in the radiologist for an RFA.

"If ultrasound guidance is used, even though it is occurring intraoperatively, you would not use 76986 (Ultrasonic guidance, intraoperative) because there is a more specific code for guidance and monitoring tissue ablation, e.g., 76490," Fulkerson says. Only if the doctor clearly indicates that the intraoperative ultrasound is a separate and distinct service, and not part of the RFA procedure, could you use both ultrasound codes along with modifier -59 (Distinct procedural service).

This latter scenario might occur if intraoperative US is used to guide the surgical resection of certain tumors and the US is also used to guide and monitor the RFA of a separate lesion. In that case both US codes would be used (with modifier -59 for 76986).

Remember that these new procedural codes are specific to RFA and should not be used to report cryosurgical 47381 (& cryosurgical) or chemical tumor ablation. In addition, these procedural codes are specific to the liver and should not be used for non-liver tumors. The guidance and monitoring codes are not specific to site or ablation method, however.