Adhere to the guidelines provided by CPT®, ACR, and payers to ensure precise reporting and appropriate reimbursement.
Diagnostic radiology encompasses a diverse array of services, including diagnostic radiology (plain film), diagnostic ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), diagnostic nuclear medicine, positron emission tomography (PET), and mammography. The following seven pointers are relevant to CPT® coding directives for diagnostic radiology, based on guidance from the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and the American College of Radiology (ACR). These tips are designed to assist coders in submitting accurate claims, especially during a period when imaging services are undergoing meticulous examination by both public and private payers.
Keep in mind: When billing a specific payer, the rules set by that payer should take precedence. It’s advisable to request payer requirements in written form and ensure that billing and coding staff have access to and are well-versed in all the payer’s regulations.
Guideline 1: Ensure Reports Fulfill Minimum Criteria
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In line with ACR directives, diagnostic imaging reports should encompass the following elements:
- Demographic details
- Pertinent clinical information
- Report body (findings)
- Impression (diagnosis or conclusion)
- Physician’s signature
- Diagnostic studies (plain films)
Please note: A resolution adopted by ACR in 2021 underscores that interpretations of medical imaging studies should only be conducted by physicians. Nonphysicians, whether working under physician supervision or as independent nonphysician healthcare providers, should not be engaged in this activity.
Guideline 2: Distinguish Professional and Technical Aspects
Many radiology procedures encompass both a technical and professional component. Fundamental to radiology coding is the coder’s need to differentiate between reporting a technical, professional, or comprehensive (global) service.
The technical component encompasses all equipment, supplies, personnel, and expenses related to the actual examination. To exclusively report the technical aspect, apply modifier TC (Technical Component).
Exception: In the case of hospital-performed services, the assumption is that the hospital bills for the technical component of each study, relieving them from the necessity of using modifier TC.
The professional component pertains to the physician’s involvement in generating a dictated report or report supervision. To solely report the physician’s work portion, use modifier 26 (Professional Component). When employing modifier 26, position it in the primary designated modifier field, as it affects the claim’s payment processing.
A global service occurs when the physician handles expenses like equipment and supplies, provides supervision, and possibly prepares the report. Global services are usually conducted within a practice setting where the physician group owns the equipment and offers dictated reports. For global services, modifiers TC and 26 are not obligatory.
For instance, when a radiologist interprets a two-view chest X-ray in a hospital setting, you would report 71046 Radiologic examination; chest, 2 views with modifier 26. In contrast, if the radiologist’s office supplies the equipment for the X-ray, you would report 71046 without any modifier.
Guideline 3: Report the Documented Number of Views Only
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The claimed number of views must satisfy the foundational requirements of the reported CPT® code. Your department’s or office’s standard view list or the predetermined number of views for a patient cannot be employed for coding purposes. The medical report must indicate the actual number of views. It’s the coder’s duty to count the views and select the corresponding CPT® code accurately.
For example, a knee exam might fall under one of four CPT® codes. To report 73564 Radiologic examination, knee; complete, 4 or more views, the documentation must confirm the presence of four or more views. If the physician’s report doesn’t explicitly state four views but mentions “AP, lateral, and both obliques,” it’s also acceptable. However, if the physician writes “multiple views of the knee,” the rules dictate reporting the lowest-level corresponding CPT® code for that study.
This principle also applies to referring physician orders. If the views or their numbers are absent from the order, the radiology office cannot impose its own standard, such as four views. Instead, the radiology department or office should communicate with the referring physician for a new order specifying the views to be performed.
Note that certain diagnostic studies demand precise view names. For instance, if the physician notes the number of abdomen views instead of listing the view names, the lowest-level code for that service must be reported.
Guideline 4: Distinguish Scout View and Contrast Studies
A scout view is a single supine view of the abdomen taken prior to gastrointestinal (GI) exams. It’s commonly known as a KUB (kidney, ureters, and bladder) image. The physician must document the film’s capture and separately dictate any findings from it.
Note: A cervical (neck) esophagram study is bundled with single and double upper GI studies. However, if medical necessity warrants a separate exam, the esophagus study (74210-74230) can be reported with modifier 59 Distinct procedural service, in addition to the upper GI studies.
When reporting a barium enema (colon) study, verify whether it’s conducted with single or double contrast. The presence of a preliminary abdomen KUB does not alter the code set.
Additional modifier tip: Several GI study codes (e.g., 74328, 74329, 74330) specify “supervision and interpretation.” These studies can be performed by one physician and interpreted by a different radiologist, both of whom can bill by appending modifier 52 Reduced services to the appropriate CPT® code. The modifier informs the payer that neither physician solely conducted or interpreted the entire study.
Guideline 5: Ensure "Complete Exam" Documentation is Comprehensive
All diagnostic ultrasound exams necessitate permanent image documentation. For abdomen and retroperitoneal studies, stringent documentation criteria must be met to code for a complete exam.
A complete abdomen study (76700 Ultrasound, abdominal, real time with image documentation; complete) necessitates documentation of the liver, gall bladder, common bile ducts, pancreas, spleen, kidneys, upper abdominal aorta, and inferior vena cava. Any missing required anatomy would necessitate downcoding the study to a limited exam (76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up)).
A complete retroperitoneum study (76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete) includes documentation of the kidneys, abdominal aorta, and common iliac artery origins. Alternatively, imaging the kidneys and urinary bladder constitutes a complete retroperitoneal study when the clinical indication for the exam involves urinary pathology.
Note: A cervical (neck) esophagram study is bundled with single and double upper GI studies. However, if medical necessity warrants a separate exam, the esophagus study (74210-74230) can be reported with modifier 59 Distinct procedural service, in addition to the upper GI studies.
When reporting a barium enema (colon) study, verify whether it’s conducted with single or double contrast. The presence of a preliminary abdomen KUB does not alter the code set.
Additional modifier tip: Several GI study codes (e.g., 74328, 74329, 74330) specify “supervision and interpretation.” These studies can be performed by one physician and interpreted by a different radiologist, both of whom can bill by appending modifier 52 Reduced services to the appropriate CPT® code. The modifier informs the payer that neither physician solely conducted or interpreted the entire study.
Guideline 6: Oral/Rectal Administration ≠Contrast
The distinction between intravenous contrast administration and oral/rectal administration is pivotal for CT and MRI coding. The alteration of code sets is contingent on whether intravenous contrast was administered. Notably, only intravenous contrast administration leads to code changes. Oral and/or rectal contrast administration cannot be billed as a “with contrast” study. To accurately report the presence of contrast, the technique section of the physician’s dictated report must explicitly mention “with IV or intravenous contrast.”
Guideline 7: Remember Supply Considerations
Diagnostic nuclear medicine studies and PET procedures do not cover the cost of radiopharmaceuticals. It’s essential for hospitals and privately owned nuclear medicine and PET departments/offices to separately report the radiopharmaceutical kit, utilizing the appropriate supply code(s).
