Follow CPT®, ACR, and payer guidelines to ensure accurate reporting and reimbursement.
Diagnostic radiology encompasses a variety 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 tips pertain to diagnostic radiology CPT® coding guidance as per American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and American College of Radiology (ACR) instructions and are intended to help coders submit accurate claims during a time when imaging services are being avidly scrutinized by public and private payers.
Remember: The payer’s rules take priority when billing that payer. Ask for payer requirements in writing, and be sure billing and coding staff have access to, and are familiar with, all payer rules.
Tip 1: Be Sure Reports Meet Minimum Requirements
Per ACR guidelines, diagnostic imaging reports should contain:
- Relevant clinical information
- Body of report (findings)
- Impression (conclusion or diagnosis)
- Physician signature
- Diagnostic studies (plain films)
Note: An ACR resolution adopted in 2021 states, “Nonphysicians should not be permitted to render interpretations of medical imaging studies, whether under physician supervision or as an independent nonphysician healthcare provider.”
Tip 2: Separate Professional and Technical Components
Most radiology procedures include both a technical component and a professional component. As a basic requirement of radiology coding, the coder must know whether to report a technical, professional, or global service.
The technical component of a service includes the provision of all equipment, supplies, personnel, and costs related to the performance of the exam. To report only the technical portion of a service, append modifier TC Technical component.
Exception to the rule: For services performed in a hospital, it’s assumed the hospital is billing for the technical component of each study, so hospitals are exempt from reporting modifier TC.
The professional component of a service includes the physician work in providing a dictated report or dictated report and supervision. To report only the physician work portion of a service, append modifier 26 Professional component. When applied, modifier 26 should be placed in the first designated modifier field because it affects how the claim will be paid.
A global service occurs when the physician bears the expense of equipment, supplies, etc., and provides supervision and/or prepares the report. Global services generally take place in an office setting, where the physician group owns the equipment and provides the dictated reports. When reporting global services, modifiers TC and 26 are not required.
For example, if the radiologist reads a two-view chest X-ray in the hospital, you will report 71046 Radiologic examination; chest, 2 views with modifier 26. If the radiologist’s office supplies the equipment with which the X-ray is performed, you will report 71046 without a modifier.
Tip 3: Report Only the Number of Views Documented
The number of views claimed must meet the basic requirements of the CPT® code reported. If your department or office has a list of standard views, or the number of views to be imaged on a patient, you cannot use it for coding purposes. The medical report must state the number of views. It’s the coder’s responsibility to count the number of views and select the correct corresponding CPT® code.
For example, a knee exam may be reported using one of four CPT® codes. To report 73564 Radiologic examination, knee; complete, 4 or more views, documentation has to substantiate four or more views. If the physician does not state four views, but rather documents “AP, lateral, and both obliques,” that is also acceptable documentation. If, however, the physician uses the phrase “multiple views of the knee,” the rules state you must report the lowest-level corresponding CPT® code for that study.
This holds true for referring physician orders, too. If the views, or the number of views, are not listed in order, the radiology office cannot impose their department standards of, for instance, four views. Instead, the radiology department or office should contact the referring physician and ask for a new order indicating the views to perform.
Note that some diagnostic studies require specific view names. For example, if the physician dictates the number of abdomen views instead of the precise names of the views, you must report the lowest-level code for that service.
Tip 4: Distinguish Scout View and Contrast Studies
A scout view is a single supine view of the abdomen taken prior to gastrointestinal (GI) examinations. It may be referred to as a KUB (kidney, ureters, and bladder). The physician must document the film was taken and dictate any findings from the film separately.
Note: A cervical (neck) esophagram study is bundled to single and double upper GI studies; however, if there is documented medical necessity to warrant a separate exam, the esophagus study (74210-74230) may be reported with modifier 59 Distinct procedural service, in addition to the upper GI studies.
When reporting barium enema (colon) study, determine if the procedure used single or double contrast. Whether a preliminary abdomen KUB is performed does not change the code set.
Bonus modifier tip: Numerous GI study code descriptors (e.g., 74328, 74329, and 74330) specify “supervision and interpretation.” These studies may be performed by a physician and interpreted by a (different) radiologist, both of whom may bill the service by appending modifier 52 Reduced services to the appropriate CPT® code. The modifier tells the payer that neither physician solely performed/interpreted the entire study.
Tip 5: “Complete Exam” Documentation Must Be Complete
All diagnostic ultrasound examinations require permanent image documentation. Abdomen and retroperitoneal studies have strict documentation requirements to code for a complete exam.
A complete abdomen study (76700 Ultrasound, abdominal, real time with image documentation; complete) requires documentation of the liver, gall bladder, common bile ducts, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava. If any one of the required anatomies is not documented, the study must be downcoded to a limited exam (76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)).
A complete retroperitoneum study (76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete) consists of documentation of the kidneys, abdominal aorta, and common iliac artery origins. Alternatively, imaging of the kidneys and urinary bladder also constitutes a complete retroperitoneal study when the clinical indication for the exam consists of urinary pathology.
Tip 6: Oral/Rectal Administration Doesn’t Count as Contrast
Whether intravenous contrast was injected determines coding for CT and MRI. Only intravenous administration of contrast changes the code sets. Oral and/or rectal contrast is not billable as a “with contrast” study. To report contrast, the technique section of the dictated report must state, “with IV or intravenous contrast.”
Tip 7: Don’t Forget Supplies
Diagnostic nuclear medicine studies and PET do not include radiopharmaceuticals. Hospitals and privately owned nuclear medicine and PET departments/offices should report the radiopharmaceutical kit separately utilizing the correct supply code(s)
For More Information: https://www.aapc.com/blog/87354-7-tips-for-diagnostic-radiology-coding/