Radiology Coding Alert

Question: I have a radiology report that indicates a CT scan was performed of the patient’s lumbar spine (L1-L3) with IV contrast at a hospital outpatient radiology department. The radiologist performed the image interpretation.

How do I report the services performed by the radiologist, who is not employed by the hospital?

Massachusetts Subscriber

Answer: You’ll start by finding the correct CPT^® code to report the computed tomography (CT) scan. In your situation, you’ll look in the AMA CPT^® Index for CT Scan > with Contrast > Spine > Lumbar. This directs you to 72132 (Computed tomography, lumbar spine; with contrast material), which you can verify in the Radiology section of the CPT^® code set.

Next, you’ll need to append modifier 26 (Professional component) to the CPT^® code. This indicates the radiologist is reporting only their professional services, such as interpreting the results and providing a written result. The hospital will bill for the technical component of the procedure since the hospital owns the CT equipment used for the procedure. The facility will follow payer preference on whether to append TC (Technical component …) to 72132.

Remember: CPT^® guidelines state, “The phrase ‘with contrast’ used in the codes for procedures performed using contrast for imaging enhancement represents contrast material administered intravascularly [into a blood vessel], intra-articularly [into a joint], or intrathecally [into the spine].” The intravenous (IV) injection of contrast in this case falls under intravascular contrast.