CHAPTER 28

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1

CHAPTER 28

RADIOLOGY


Radiology

• Radiology: Branch of medicine that uses radiant energy to diagnose and treat patients

• Specialist in radiology: Radiologist (doctor of medicine)


Radiology Subsections

• Diagnostic Radiology– Aorta & arteries

• Diagnostic Ultrasound

• Radiologic Guidance

• Breast, Mammography

• Bone/Joint Studies

• Radiation Oncology– Clinical Brachytherapy

• Nuclear Medicine


Terms

• Fluoroscopy views inside of body, projects onto television screen

• Live images by which physician can view function and structure of organ

– Example: 71034, Chest x-ray with fluoroscopy


Magnetic Resonance Imaging

• MRI uses magnetic energy to view soft tissue structures

– Example: 72148, MRI of lumbar spine canal

(Cont’d…)


MRI

(…Cont’d)

• MRA—Magnetic Resonance Angiography—is application of MRI that provides visualization of blood flow, as well as images of normal and diseased blood vessels

Figure: 28.12Modified from Bradley WG, Daroff RB, Fenichel GM, Jankovic J: Neurology in Clinical Practice, ed 5, Philadelphia, 2008, Butterworth-Heinemann.


Tomography or CT

• Tomography used to view single plane of body

– Example: 70450, Tomographic scan of head or brain

(Cont’d…)


CT Scan of Lung Carcinoma

(…Cont’d)

A, A patient with right hilar lung carcinoma and mediastinal adenopathy showing the margins of the bones.

B, The scan can be set to show the soft tissue.

C, The lung organs can be shown by using additional scan settings. There is greater detail than would be obtained with conventional radiographs.

(Courtesy of Bruce Porter, MD.)


Biometry

• Biometry: Application of statistical methods to biological facts

– Example: 76516, Use of ultrasound echography in biometry of eye

• Ultrasound diagnostic non-invasive procedures are performed to determine composition and contours of ocular and orbital structures


Planes of Body

Figure: 28.1

• Imaginary lines used as points of reference


Position and Projection

• Position: Way in which patient placed

• Projection: Path x-ray beam travels


Terminology

• Radiology uses a wide variety of terms and abbreviations specific to planes, positions, and projections


Component Coding

• Three component terms

– Professional

– Technical

– Global


Professional Component (-26)

• Physician portion of service, includes

– Supervision of technician

– Interpretation of results, including written report

From Young AP, Proctor DB: Kinn's The Medical Assistant, ed 10, St. Louis, 2007, Saunders.


Technical Component (-TC)

• Technologist’s services

• Equipment, film, and supplies

From Long BW, Frank ED, Ehrlich RA: Radiography Essentials for Limited Practice, ed 2, St. Louis, 2006, Saunders.


Global Procedure

• Both professional and technical portions of radiology service

• If facility where procedure was performed owns the equipment and has a radiologist on staff who reads the report global service

– No -TC

– No -26


Component Modifiers

• If only professional component of radiology service provided append -26 to code

(Cont’d…)


Component Modifiers

(…Cont’d)

• If only technical component was provided append -TC to code

– -TC: HCPCS modifier used with CPT and HCPCS codes


Global Procedure

• If both professional and technical components of radiology service provided, use no modifier

(Cont’d…)


For Example: Chest X-Ray

(…Cont’d)

• Professional component:

– 71030-26 (Supervision and final report)

• Technical component:

– 71030-TC (Technician, supplies, equipment)

• Global procedure: 71030 (both professional and technical)

(Cont’d…)


Global Procedure

(…Cont’d)

• Third-party payers usually reimburse

– 40% professional component

– 60% technical component

– 100% global procedure


Contrast Material

• Statement “with contrast” implies injection built into code

(Cont’d…)


Contrast Material

(…Cont’d)

• Notes indicate codes for components

– Example: 75893, venous sampling indicates “(For procedure, use 36500)”

• Oral or rectal contrast does not qualify for “with contrast”


Overview of Radiology Subsections

• Diagnostic Radiology

• Diagnostic Ultrasound

• Radiologic Guidance

• Breast, Mammography

• Bone/Joint Studies

• Radiation Oncology

• Nuclear Medicine


Diagnostic Radiology

• “Complete” in a code description in radiology section, means all views taken of specified body site

• Most standard radiographic procedures

• Codes often divided on whether contrast material used

• Codes further divided on number views

(Cont’d…)


Diagnostic Radiology

(…Cont’d)

• Used to:

– Diagnose disease

– Monitor disease process—progression or remission


Diagnostic Procedures Include

• X-ray

• Computerized axial tomography (CAT or CT scan)

• Magnetic resonance imaging (MRI)

• Angiography

Subdural hematoma

CT of renal artery

From Mettler FA: Essentials of Radiology, ed 2, Philadelphia, 2005, Saunders.

From Mettler FA: Essentials of Radiology, ed 2, Philadelphia, 2005, Saunders.

From Walsh PC, editor: Campbell's Urology, ed 8, Philadelphia, 2002,

Saunders.


Computerized Axial Tomography

• X-ray image taken in sections

• Computer reconstructs and enhances image


Magnetic Resonance Imaging

• Uses magnetic fields to produce an image displayed on computer screen

• Codes of same area (e.g., spine) divided on whether or noT contrast material used


Angiography

• Used to view vessel obstructions

• Dye injected into vessel

(Cont’d…)


Angiography

(…Cont’d)

• Angiography of aortic arch and brachio-cephalic vessels

(Cont’d…)

Figure: 28.13

From Stimac GK: Introduction to Diagnostic Imaging, Philadelphia, WB Saunders, 1992, p 447.


Angiography

(…Cont’d)

• Radiologist uses angiography to diagnose vascular conditions

• Examples:

– Malformations

– Strokes

– Myocardial infarctions


Remember

• If fewer than total number of views specified in code provided:

– Use -52, Reduced Service


Diagnostic Ultrasound

• Uses high-frequency sound waves to image anatomic structures

• Audible sound waves bounce off body tissues and then are recorded to give information about anatomy of an internal organ

(Cont’d…)


Diagnostic Ultrasound

(…Cont’d)

• Ultrasound showing a gallstone

Figure: 28.14From Goldman L, Ausiello D, eds: Cecil Medicine, ed 23, Philadelphia, 2008, Saunders.


Subheadings

• Subheadings of Diagnostic Ultrasound primarily based on anatomy

• Example:

– Head and Neck

– Chest

– Pelvis

• Many notes in subsection directing correct assignment


Three Locations For Ultrasound Services

• 76506-76999: Radiology codes for diagnostic ultrasound services

• 93880-93990: Medicine codes for vascular studies

• 93303-93352: Medicine codes for echocardiography


Interventional Radiologist

• Combination radiologist and surgeon

• Provides total procedure for cystography with contrast

– Report 74430, X-ray portion and

– 51600 for injection procedure,

– Plus code for supply of contrast material (e.g., 99070 or HCPCS code)


Ultrasound Modes and Scans

• A-mode or A-scan technology—one-dimensional

• M-mode—one-dimensional measurement procedure with movement of trace to allow amplitude and velocity of moving echo-producing structures

• B-scan technology—two-dimensional

• Real-time scan

• A & B scan may be performed together (medical necessity documented)


A-Mode

• A = Amplitude

• Technique used to map structure outline

• Displays one-dimensional image


M-Mode

• M = Motion

• Technique used to display movement of structure

• Displays one-dimensional image


B-Scan

• B = Brightness

• Technique used to display movement of tissues and organs

• Known as gray scale ultrasound

• Displays two-dimensional image


Real-Time Scan

• Technique used to display both structure and motion with time of organ and tissues

• Displays two-dimensional image


Extent of Study

• Codes often divided on extent of study

• Example: Extent of scan as follows

(Cont’d…)


Extent of Study

(…Cont’d)

• Complete: Scans entire body

• Limited: Scans part of body, i.e., one organ

• Follow-up/repeat: Limited study of part of body that was scanned previously


Radiologic Guidance, Breast, Mammography, Bone/Joint Studies, and Radiation Oncology

• Radiologic Guidance (77001-77032)– Fluoroscopic, computed tomography, magnetic resonance

guidance, and other

• Breast, Mammography (77051-77059)– Such as screening, and computer-aided detection

• Bone/Joint Studies (77071-77084)– Such as bone density and joint survey

• Radiation Oncology (77261-77799)– Therapeutic use of radiation

– Codes for both professional and technical services

– Subheading divided based on treatment


Radiation Oncology

• Initial consultation, prior to decision to treat, reported with E/M Consultation code

– Outpatient: 99241-99245

– Inpatient: 99251-99255

• Follow consultation criteria: Document who and why


Clinical Treatment Planning—Professional Component

• Includes:

– Interpretation of special testing

– Tumor localization

– Determination of treatment volume

(Cont’d…)


Clinical Treatment Planning

(…Cont’d)

• Choice of treatment method

• Determination of number of treatment ports

• Selection of treatment devices

• Other necessary procedures

(Cont’d…)


Clinical Treatment Planning

(…Cont’d)

• Clinical Treatment Planning consists of

– Three types of treatment plans

– For all patients requiring radiation therapy


Levels of Planning (77261-77263, 77299)

• Simple: One treatment area, one port or one set of parallel ports

• Intermediate: Three or more ports, two separate treatment areas, multiple blocking

(Cont’d…)


Levels of Planning

(…Cont’d)

• Complex: Complex blocking, custom shielding blocks, tangential ports, special wedges, or compensators, three or more treatment areas, special beams

• Unlisted procedure (77299)


Simulation (77280-77295)

• Determines placement of treatment areas/ports for radiation treatment

• Does not include administration of radiation

(Cont’d…)


Four Levels of Simulation

(…Cont’d)

• Simple: One treatment area with one port or pair of ports

• Intermediate: Three or more ports, two separate treatment areas, multiple blocking

• Complex: Tangential ports, three or more treatment areas, complex blocking

• 3D: Computer generated three-dimensional image of tumor


Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services (77300-77370, 77399)

• Decision-making services of physicians

– Treatment types

– Dose calculation and placement (dosimetry)

– Development of treatment device

• Stereotactic Radiation Treatment Delivery (77371-77373)

– Pay close attention to notes

• Delivers large dose to specific tumor site


Radiation Treatment Delivery (77401-77423, 77520-77525)• Radiation (77401-77421)

• Neutron Beam (77422, 77423)

• Proton Beam (77520-77525)

• Technical component of actual delivery of radiation

– MeV (electrons)

– Neutrons

– Protons


Information Needed to Code Radiation Treatment Delivery

• Amount of radiation delivered

• Type of radiation—electron (most common), neutron, or proton

(Cont’d…)


Information Needed to Code Radiation Treatment Delivery(…Cont’d)

• Number of

– Areas treated (single, two, three or more)

– Ports involved (single, three or more, tangential)

– Blocks used (none, multiple, custom)


Reporting Radiation Treatment Management (77427-77499)• Professional (physician) portion of services,

including:– Review port films

– Review dosimetry, dose delivery, treatment parameters

– Treatment set-up

– Patient examination for medical E/M

– Report in units of five fractions• Unless last 3-4 fractions are at the end of the treatment

– Count the last 3-4 as an additional fraction


Clinical Brachytherapy (77750–77799)

• Placement of radioactive material into or around site of tumor:

– Intracavitary(within body cavity)

– Interstitial(within tissues)

(Cont’d…)

From Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG: Clinical Oncology, ed 3, Philadelphia, 2004,

Churchill Livingstone.


Source

(…Cont’d)

• Radioactive element delivers radiation dose over time

– Examples: Seeds, ribbons, or capsules

– Ribbons: Seeds embedded on tape

• Tape cut to desired length controls amount of radiation and inserted into tissue

(Cont’d…)


Clinical Brachytherapy Codes Divided Based On(…Cont’d)

• Number of sources applied:

– Simple: 1-4

– Intermediate: 5-10

– Complex: 11+


Nuclear Medicine

• Placement of radioactive material into body and measurement of emissions

• Used both for diagnosis and treatment

– Example: Stress test

(Cont’d…)


Nuclear Medicine

(…Cont’d)

• Codes divided primarily on organ system

– Exception: “Therapeutic,” for radiopharmaceutical therapies


Positron Emission Tomography (PET)

• 78811-78816

• Based on location(such as, skull base or chest)

• Non-invasive imaging procedure that assesses perfusion and level of metabolic activity in various organ systems

PET lesions in the liver

From Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG: Clinical Oncology, ed 3, Philadelphia, 2004, Churchill Livingstone.


ConclusionCHAPTER 28RADIOLOGY

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CHAPTER 28