A structured and updated summary of the 2025 Radiology Coding Guidelines, covering procedural codes (CPT), diagnostic codes (ICD-10-CM), and inpatient procedural coding (ICD-10-PCS), along with essential best practices.
MAMMOGRAM CODING UPDATES
| CPT Code Changes | No mammography-specific code changes in 2025; general code set updated. |
| NCCI Guidelines | Emphasis on specificity and avoiding unbundling. |
| CAD in MRI | CAD included in 77048/77049, no extra billing allowed. ( UHC ) |
| Contrast Agents | Contrast not inherent to digital mammography; separate billing may require payer guidance. |
| Modifier GG | Required for diagnostic mammograms with thorough documentation. |
| Screening Guidelines | USPSTF now recommends biennial screening from age 40 to 74. |
Payer-Specific Coding Clarifications
- According to United Healthcare, effective May 1, 2025, Computer-Aided Detection (CAD) is already included in MRI breast codes (77048 and 77049). Additional charges for CAD are therefore not permissible when performing breast MRI.
- Hologic’s 2025 Mammography Coding Guide (published January 2025) notes that contrast administration codes (96365–96379), while intrinsic to many imaging services, are not inherent to digital mammography. Therefore, billing for contrast is potentially allowable in addition to digital mammography—but payer-specific guidance should be consulted.
Updated Diagnosis Coding Standards
The following ICD-10 code changes are relevant to radiologists:
Anal, Rectal, and Anorectal Fistulas
New 5th and 6th character codes provide greater specificity, distinguishing between simple and complex cases, and identifying initial, persistent, or recurrent conditions. Detailed documentation of these aspects is essential for accurate coding.
- 30- Anal fistula, unspecified
- 31- Anal fistula, simple
- 32- Anal fistula, complex
- 33 – Anal fistula, persistent
- 34- Anal fistula, recurrent
Pulmonary Embolism
Expanded codes now specify causes, including cement or fat embolism, enhancing the precision of radiological reporting.
- 92 – Other pulmonary embolism without acute cor pulmonale
- 93- Other pulmonary embolism with acute cor pulmonale
Synovitis and Tenosynovitis
Additional codes enable the precise location specification of unspecified synovitis and tenosynovitis, facilitating detailed imaging reports.
- 871- Other synovitis and tenosynovitis, right ankle and foot
- 872- Other synovitis and tenosynovitis, left ankle and foot
- 879- Other synovitis and tenosynovitis, unspecified ankle and foot
Lymphoma
Updates offer further specificity in types of lymphoma and include expanded codes to identify cases in remission, which is crucial for imaging follow-ups.
- 33- Diffuse large B-cell lymphoma, intrathoracic lymph nodes
- 36 – Diffuse large B-cell lymphoma, intrapelvic lymph nodes
- 88- Other specified types of non-Hodgkin lymphoma, other sites
Hypoglycemia and Obesity
Both conditions are now categorised into levels 1-3, necessitating detailed documentation to support appropriate imaging studies.
- 3- Other specified hypoglycemia
- 01- Morbid (severe) obesity due to excess calories
- 09- Other obesity due to excess calories
Breast Cancer Biomarkers
New Z codes indicate PR and HER-2 status, to be used alongside breast cancer diagnoses, facilitating tailored imaging protocols.
- 850- Personal history of malignant neoplasm of breast
- 0- Estrogen receptor positive status [ER+]
- 1- Estrogen receptor negative status [ER-]
- 2- Progesterone receptor positive status [PR+]
- 3 – Progesterone receptor negative status [PR-]
- 4- HER-2 positive status
Personal History of Colon Polyps
Expanded codes specify adenomatous/serrated, hyperplastic, or other types of colon polyps, important for imaging surveillance strategies.
- 010- Personal history of adenomatous polyps of colon
- 011- Personal history of hyperplastic polyps of colon
- 012- Personal history of other specified polyps of colon
MODIFIERS: Final Takeaways for Radiology Coders:
- Radiology-specific modifiers were not added for 2025, but please confirm whether your practice uses the broader modifier 54 policy for global surgeries.
- Use the new audio-only codes for telehealth services (especially for overlapping radiology functions like consultations and follow-ups) and omit modifier 93 as per CMS policy.
Key Highlights for Radiology in MIPS 2025
MIPS Thresholds and Category Weighting
- The MIPS performance threshold will remain at 75 points through CY 2027.
- The data completeness threshold remains at 75% for the MIPS Quality Performance Category through the CY 2028 performance period, possibly rising to 80% in CY 2029.
- There are no changes in 2025 to how the four MIPS reporting categories are weighted: Quality, Improvement Activities, Cost, and Promoting Interoperability. However, your Special Status (such as small practice or non–non-patient-facing designation) will still influence category weighting for individuals and groups. Be sure to review your Special Status in December 2025 to see if any categories will be reweighted.
1. Quality Category — Greater Scoring Potential
The 7-point cap on highly topped-out radiology quality measures has been removed, allowing each such measure to earn up to 10 points. This significantly boosts scoring potential.
Impacted measures include:
- #360: CT and cardiac nuclear medicine studies count (OPEIR)
- #364: Follow-up CT recommendations for incidental pulmonary nodules.
- #405: Follow-up imaging for incidental abdominal lesions.
- #406: Follow-up recommendations for incidental thyroid nodules.
- Example: A practice scoring 74.5 in 2024 might achieve 16 in 2025 for the same performance ..Note: One measure was removed entirely:
- #436 – Radiation Consideration for Adult CT — Utilisation of Dose Lowering Techniques
Benchmarking change:
Radiology group that earned 74.5 points in 2024 under the topped-out model would now achieve a score of 97.16 for the same metrics and performance in 2025.
| Measure | Performance Rate (%) | Decile Score |
| 360 | 100% | 10 |
| 364 | 100% | 10 |
| 405 | 99% | 9 |
| 406 | 99% | 9 |
| 322 | 100% | 10 |
| 145 | 100% | 10 |
| Total Quality Points | 58 | |
| Estimated MIPS Score | 97.16 | |
New Quality Measure Introduced
- Measure #494 — Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT in Adults:
- An eCQM (electronic Clinical Quality Measure) focusing on CT exam quality and radiation dosing.
- Requires software to extract data directly from radiology EHR systems.
3. QCDR Measures via ACR’s National Radiology Data Registry (NRDR)
Radiology practices can leverage additional reporting options through ACR’s Qualified Clinical Data Registry. In 2025, five new measures are available:
- ACRad 43: DXA — Reporting true change in bone mineral density
- QMM 23: Low-dose cancer screening recommendation for chest CT with emphysema diagnosis
- QMM 24: Acute rib fracture numbering on ED trauma patients
- QMM 27: Classification and follow-up imaging for incidental pancreatic cysts
- QMM 28: Reporting breast arterial calcification (BAC) on screening mammography
4. Improvement Activities (IA) — Simplified Requirements
- CMS has streamlined activity requirements:
- Special-status practices (small, non-patient facing, rural) only need to attest 1 activity.
- Most other practices must attest 2 activities for the performance year.
- Some radiology-specific IAs have been retired, such as:
- Providing 24/7 clinician access
- Referral closure improvements
5. Cost and Promoting Interoperability (PI) Categories
- Cost Category: According to CMS, the average performer now gets around 7.5 points, with greater upside for cost-effectiveness.
- Promoting Interoperability: Remains voluntary for many hospital-based radiologists. If exempt, its weight shifts to Quality, increasing its share of total scoring.
- MIPS Value Pathways (MVPs) — Not Yet for Radiology
Radiology-specific MVPs are not available in 2025. CMS has, however, proposed an MVP for Interventional Radiology beginning in performance year 2026.Summary Table
| Category | 2025 Updates for Radiology |
| Quality | No 7-point cap → up to 10 points per topped-out measure; new Measure #494 added |
| QCDR (ACR NRDR) | Five new registry measures available for reporting |
| Improvement Activities (IA) | Simplified attestation (1 for special-status, 2 for others); selected radiology IAs retired |
| Cost | Scoring recalibrated → higher baseline points, broader scoring range |
| Promoting Interoperability | Often exempt for radiology; exemption shifts weight to Quality |
| MVPs | No Radiology-specific MVP yet (proposed IR MVP from 2026) |
Medicare Physician Fee Schedule (PFS) & Reimbursement Trends
Conversion Factor (CF) & Overall Payment Updates for 2025
- 2025 Conversion Factor (CF): The CF for 2025 is $32.3465, a 83% decrease from 2024’s $33.2875. This drop reflects the expiration of a temporary payment adjustment at the end of 2024. The financial impact will vary depending on each practice’s procedure volume, service site mix, modality charges, and billing arrangements. Radiology groups should plan for potential revenue changes and adjust budgets accordingly.
- PFS Final Rule Impact: The 2025 Medicare Physician Fee Schedule (PFS) introduces an across-the-board 2.93% cut to imaging reimbursement. Coding rules remain largely unchanged, so the primary focus for practices should be on revenue modelling and operational planning using updated fee schedules.
New and Updated ICD-10-PCS Codes (Procedures)
The FY 2025 ICD-10-PCS code set introduces 371 new procedure codes, deletes 61 codes, and revises several titles—mainly in the Medical & Surgical and New Technology sections.
1. Examples of key new entries include:
- A new table for bypass of lymphatic structures.
- Codes for lumbar artery perforator flap used in post-mastectomy breast reconstruction.
- Fibre-optic 3D guided procedures in endovascular surgery.
- Technology-related additions like everolimus-eluting resorbable scaffolds and intraluminal bioprosthetic valve leaf splitting.
2. An April 1, 2025, update adds 50 more ICD-10-PCS codes, including:
- A new table for trachea-to-esophagus bypass procedures.
- Updates to the obstetric and administration
- A new table in Radiation Therapy for stereotactic radiosurgery targeting the heart and great vessels
- Note: 2025 Official ICD-10-PCS Guidelines remain unchanged, meaning coding conventions and structure remain consistent with prior editions.
Radiology Coding & Documentation Guidelines
1. Focus on what was actually done, not what was ordered.
Common Coding Pitfall:
A frequent error in radiology coding is coding based on what was ordered rather than what was performed. For example, an order may state “CT with contrast,” but if contrast was not administered or the study was completed as a non-contrast scan, coding must accurately reflect the actual procedure performed.
Quick reminder:
In radiology, “contrast” = IV contrast. Not oral. Not rectal. That confuses a lot of coders, especially when reports casually mention contrast without specifics.
2. The order determines the diagnosis code; findings should not drive coding
Coding Principle:
When coding radiology exams, the clinical indication for the study—not incidental findings—should guide your primary diagnosis selection.
Example:
If an exam was ordered for back pain, that symptom remains the primary diagnosis, even if the radiology report identifies a herniated disc, incidental cyst, or any unexpected finding.
Common pitfall:
Coding every finding, even if it had nothing to do with the patient’s symptoms. Unless the radiologist suggests follow-up or says it’s clinically significant, don’t list it just because it’s there.
3. Always confirm whether your claim should reflect the global service, professional component, or technical component based on documentation, setting, and contracts.
Global Component
- Represents both the technical and professional portions of a service.
- Used when the same provider or entity performs both the imaging and interpretation.
Professional Component (Modifier 26)
- Covers only the physician’s work: supervision, interpretation, and reporting.
- Appended when the radiologist interprets images but does not own the equipment.
Technical Component (Modifier TC)
- Includes the facility costs, such as equipment, supplies, and technologist time.
- Billed when only the imaging was performed without interpretation by the billing provider.
Key takeaway
- Who owns the machine?
- Who read the scan?
- What location is listed?
4. Avoid Assumptions with Bundled Services
Key Principle:
Many imaging services already include components that are not separately billable. For example:
- CT scans inherently include scout images.
- Fluoroscopy is often integral to interventional procedures.
Just because a component appears in the radiology report does not automatically make it billable. Attempting to unbundle included services is one of the fastest ways to trigger payer scrutiny or audit flags.
5. Modifiers Are Important—Use Them Judiciously
Best Practices:
- Apply modifiers only when documentation clearly supports their use.
- Common radiology modifiers include:
- 26 – Professional component
- TC – Technical component
- 59 / XU / XE / XS / XP / XS – Distinct procedural service
- 76 / 77 – Repeat procedure
- Ensure modifiers align with CPT®, NCCI, and payer guidelines to maintain compliance.
Bottom Line:
Proper use of modifiers optimises reimbursement, enhances claim accuracy, and reduces audit risk.
6. Templates Support, But Do Not Replace, Coding Judgment
Best Practices:
- Review and verify every code against the procedure performed and documented findings.
- Ensure templates are updated regularly to reflect current CPT®, ICD-10, and payer guidelines.
- Use templates as a tool for efficiency, not as a substitute for professional coding judgment.
Bottom Line:
Accurate coding requires active review and critical thinking—templates can aid workflow, but cannot replace compliance and clinical accuracy
7. Interventional Radiology Coding Is Its Own Beast
Common trip-up:
While templates and pre-filled reports can streamline documentation, they should never drive the coding decision. Relying solely on a template may lead to inaccurate codes that do not reflect the actual services performed