Coding Changes in 2010

What you need to know

The release of CPT® 2010 brings with it approximately 30 code revisions, additions, and deletions relevant to radiology, along with new Radiology Guidelines defining a special report.

Diagnostic Radiology

Within diagnostic radiology, changes affect spine, gut, heart, and vascular codes. The introduction of two new Category III codes to describe sacral augmentation (0201T and 0202T) called for revision of 72291: “Radiological supervision and interpretation, percutaneous vertebroplasty, or vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum, under fluoroscopic guidance;” and 72292: “Radiological supervision and interpretation, percutaneous vertebroplasty, or vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum, under CT guidance.”

A parenthetical reference following new Category II sacroplasty codes 0201T and 0202T directs coders to 72291 and 72292 for radiological supervision and interpretation.

Three new codes now report CT colonography. Also called “virtual colonoscopy,” CT colonography provides a noninvasive alternative to conventional colonoscopy. Images are taken using CT, and a computer merges the images to create an animated, 3-D view of the inside of the large intestine.

Codes 74261: “Computed tomographic (CT) colonography, diagnostic, including image postprocessing, without contrast material;” and 74262: “Computed tomographic (CT) colonography, diagnostic, including image postprocessing, with contrast material(s) including non-contrast images, if performed,” replace now-deleted Category III code 0066T.

Code 74263: “Computed tomographic (CT) colonography, screening, including image postprocessing” is a screening, rather than diagnostic, procedure, and includes contrast. This code replaces 0067T, which has been deleted for 2010.

CPT® Guidelines prohibit reporting 74621, 74622, or 74623 with related CT services, including 72192-72194, 74150-74170, 74261, 74262, 76376, and 76377.

Codes also have been added to describe CT of the heart. Code 75571: “Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium” is specific to quantitative evaluation of coronary calcium for diagnosis of coronary artery disease. Codes 75572: “Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3-D image post-processing, assessment of cardiac function, and evaluation of venous structures, if performed);” and 75573: “Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3-D image post-processing, assessment of LV cardiac function, RV structure and function, and evaluation of venous structures, if performed)” describe evaluation of cardiac structure and morphology, and both include injection of contrast; 77573, however, is specific for those patients with congenital heart disease.

New code 75574 describes CT angiography (CTA) of the heart, coronary arteries, and any bypass graft(s) present. It includes injection of contrast. Additional CPT instructions specify, “Contrast enhanced cardiac CT and coronary CTA codes 75571-75574 include any quantitative assessment when performed as for of the same encounter,” and “Report only one computed tomography heart service per encounter.” Codes 75571-75574 replace now-deleted Category III codes 0144T-0151T.

Cardiac MRI codes 75558-75564, which included velocity flow quantification and/or stress imaging, have been deleted. For cardiac MRI with velocity flow imaging, report an appropriate service from 77557, 77559, 77561, or 77563 – which carry over from previous years – and report in addition new add-on code +75565: “Cardiac magnetic resonance imaging for velocity flow mapping (list separately in addition to code for primary procedure).”

Added instructions preceding “heart” codes 75557-75791 specify: “Use 75559 with 75565 to report flow with pharmacologic wall motion stress evaluation without contrast. Use 75563 with 75565 to report flow with pharmacologic perfusion stress with contrast,” and “Only one add-on code for flow velocity can be reported per session.” Additionally, you should not report 75565 with 3-D rendering codes 76376 or 76377.

Lastly, 75790 has been deleted, to be replaced by new angiography code 75791: “Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation.”

AMA instruction stipulates, “Do not report 75791 in conjunction with 36147, 36148,” and “Use 75791 only if radiological evaluation is performed through an already existing access into the shunt or from an access that is not a direct puncture of the shunt.”

Radiologic Guidance

CPT 2010 includes six new codes for paravertebral facet joint injections (64490-64495). Unlike the now-deleted codes (64470-64476) previously used to report these procedures, 64490-64495 specifically include image guidance (either fluoroscopy or CT). As such, the descriptor for 77003: “Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, or sacroiliac joint, including neurolytic agent destruction)” has been revised to delete reference to the paravertebral facet joint. Code 77003 should not be reported with 64490-64495.

Radiation Oncology

A code has been added to describe design and construction of multi-leaf collimator (MLC) device(s). MLCs are used during intensity-modulated radiation therapy (IMRT). The individual “leaves” of the device move independently to block, or allow passage, of particle beams to regulate dose delivery. The device is custom-designed for each patient. Previously, IMRT treatment devices were billed using 77334: “Complex Treatment Device,” but for 2010 will be reported with 77338: “Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design, and construction per IMRT plan.”

Code 77338 applies only once per IMRT plan and does not apply to devices used with compensator-based IMRT (0073T). For immobilization in IMRT treatment, look to codes 77332-77334.

Nuclear Medicine

A new instruction heads the “Cardiovascular System” codes 78414-78499: “Myocardial perfusion and cardiac blood pool imaging studies may be performed at rest and/or during stress. When performed during exercise and/or pharmacologic stress, the appropriate stress testing code from the 93015-93018 series should be reported in addition to 78451-78454, 78472-78492.”

The instruction refers to new codes 78451-78454, which replace now-deleted codes 78460-78480 for myocardial perfusion studies. The new codes combine the previous codes to reflect the current practice of performing myocardial perfusion planar, SPECT, wall motion, and ejection fraction services at the same setting by the same provider, as follows:

• 78451 – Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic).
• 78452 – Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.
• 78453 – Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic).
• 78454 – Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection.

Radiology Special Report

A new instruction regarding special reports has been added to the Radiology Guidelines for 2010, which specify: “A service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature extent, and need for the procedure; and the time effort, and equipment necessary to
provide the service.”

Don’t Forget ICD-9-CM

Although CPT changes garner much of the attention when it comes to new coding information, successfully integrating ICD-9-CM changes is equally important. And, whereas CPT changes aren’t adopted until the Jan. 1, 2010, ICD-9-CM changes already are in effect (as of Oct. 1, 2009). Perhaps the single most significant change for radiology practice is the revision of category 793: “Nonspecific (abnormal) findings on radiological and other examination of body structure,” to include new code 793.82: “Inconclusive mammogram.”

During routine mammogram, dense breasts may lead to inconclusive findings. Although dense breasts are not considered an abnormality, the finding often is a reason for further testing to confirm that no malignancy is present. Additionally, the descriptor for 793.89: “Other (abnormal) findings on radiological examination of breast,” was revised so that the term “abnormal” isn’t necessary, thereby allowing coding for an inconclusive test that is not necessarily abnormal.

Additionally, the latest ICD-9-CM update includes two new codes to identify torus fracture: – 813.46: “Torus fracture of ulna (alone)” and 813.47: “Torus fracture of radius and ulna.” Torus fractures, also called “buckle fractures,” are a type of incomplete fracture common among children. The softer bone of a child may buckle upon itself on one side, leaving the other side undisturbed. For instance, falling on an outstretched hand may result in a torus fracture. The new codes should not be confused with 813.45: “Torus fracture of radius” and other radius and ulnar fracture codes specified in the 813.xx: “Fracture of radius and ulna” range.

Finally, 832.2: “Nursemaid’s elbow” has been added to the ICD-9-CM code set to describe subtle subluxation of the elbow joint (as would happen, for instance, if an adult pulls too hard on a child’s arm – hence the name “nursemaid’s elbow”). The diagnosis is made upon X-ray exam, showing the radial head out of position (subluxation of the radial head). Most likely, you will use 832.2 for pediatric patients between 1 to 3 years of age. Note that the fifth digit identifying anatomic site of the dislocation that applies to all of the other codes in category 832 does not apply to 832.2.

– G.J. Verhovshek, MA, CPC, is director of clinical coding content at the American Academy of Professional Coders (AAPC) in Salt Lake City. Direct questions and comments to editorial@rt-image.com.