Radiology Coding Alert

Question: Our freestanding imaging center performs a CT of the sinuses without contrast (images/data scans taken in order to obtain computerized data, which will enable use of the automated equipment, Instatrak) and submits this data to the surgeon who uses these images to build a 3D image with the Instatrak for guidance during surgery. 

The radiologist dictates findings from the scans and puts them in a report as "CT sinuses w/3D." We can print hardcopy images from the data at any time, and they are permanent files.

How should I report the test?


Florida Subscriber

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

The bigger question is whether you should report the 3D rendering. From your description, the radiologist neither supervises the creation of 3D images nor interprets them.

Result: You should not 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).

CPT Changes 2006 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."

If your service meets those requirements, you may use the 3D rendering codes.