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Reporting radiology procedures throughout the CPT Manual

JustCoding News: Outpatient, May 28, 2014

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By Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I
 
Twenty-first century healthcare provides patients with more minimally invasive surgical options that ever before. For many of these procedures, the healthcare professional performing the service is a board-certified interventional radiologist.
 
For professional coding specialists, as the role of radiologists has expanded, so does the reporting of these procedures using CPT® codes. These procedures are now reported with codes from other sections of the book, in addition to the Radiology section.
 
Angiography
During an angiography, x-rays are used to identify obstruction or stenosis of an artery or vein, as well as other problems with the cardiovascular system. Contrast dyes may be administered to illuminate a specific vessel to enable visualization of blood flow and blockages.
 
Examples include:
  • 73225, magnetic resonance angiography, upper extremity, with or without contrast material(s)
  • 75658, angiography, brachial, retrograde, radiological supervision and interpretation
  • 93571, intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacology-induced stress
 
Balloon angioplasty and stent placement
When arterial or venous stenosis or obstruction is diagnosed, a radiologist can insert a catheter with a special tip into an artery. The catheter is threaded up to the site of the stenosis and the balloon in the tip is inflated and then deflated and removed. The gentle pressure of the balloon reinstates the walls of the vessel back to the original position.
 
If the physician determines the vessel may collapse again, the tip of the catheter can deliver a stent (intraluminal device or drug-eluting intraluminal device) and place it within the vessel to support the open position. Renal arterial stenosis (narrowing of the arteries in the kidneys), often resulting in renal hypertension, can also be treated with angioplasty. 
 
Code examples include:
  • 35471, transluminal balloon angioplasty, percutaneous; renal or visceral artery
  • 37217, transcatheter placement of an intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, via open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation
  • 75978, transluminal balloon angioplasty, venous (e.g., subclavian stenosis), radiological supervision and interpretation
  • 92974, transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy
 
Gastrostomy tube
Various circumstances may require a patient to obtain nutrition while avoiding the mouth and esophagus. This may be a patient with dysphagia (difficulty in swallowing) or a baby with a congenital anomaly of the mouth or esophagus, such as esophageal atresia. A gastrostomy tube, also known as a feeding tube, can be inserted percutaneously directly into the stomach or the jejunum.
 
Examples:
 
  • 49440, insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
  • 49441, insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
 
Needle biopsies
The only way to determine whether a mass or lump is malignant is to obtain tissue specimens for pathologic evaluation. As an alternative to surgical biopsy that requires an open approach, a needle biopsy is less traumatic for the patient.
 
Radiologic guidance is required to pinpoint the tip of the needle directly into the tumor. This method can be used for diagnostic testing of lumps identified in the breast, lungs, and other anatomical sites. Coders must carefully distinguish between a “fine needle aspiration” and a “percutaneous needle biopsy.”
 
Examples:
  • 10022, fine needle aspiration; with imaging guidance
  • 19083, biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance
  • 77002, fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
 
Radiofrequency ablation
Interventional radiologists can use radiofrequency (RF) energy to interrupt chronic pain sensations (such as back pain) or to destroy malignant cells and tumors (such as hepatocellular carcinoma). For pain control, RF uses radio waves or electrical current to generate a level of heat that will result in an interruption of nerve conduction. This is typically a semi-permanent solution, lasting six to nine months, on average.
 
For the destruction of malignant cells, imaging (ultrasound, CT, or MRI) is used for guidance to ensure the needle electrode tip penetrates the tissues of the tumor. Then, high-frequency electrical currents are emitted through the needle, and the abnormal cells are destroyed.
 
Examples:
  • 32998, ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral
  • 41530, submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session
  • 47382, ablation, 1 or more liver tumor(s), percutaneous, radiofrequency
  • 50592, ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency
 
Vertebroplasty and kyphoplasty
Patients suffering with compression fractures of the vertebrae deal with constant pain. During vertebroplasty, image guidance enables the precise injection of a special type of cement directly into the broken area of the vertebra.
 
When kyphoplasty is performed, image guidance permits the needle to enter into the compressed segment of the bone. Then, a balloon in the tip of the needle is inflated, lifting the collapsed section back into original alignment. Finally, the balloon is deflated and the cavity is filled with special cement to hold the form in place.
 
Examples:
  • 72291, radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance
  • 72292, radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under CT guidance
 
 
Vena cava filter
When a patient is diagnosed with peripheral thrombi, there is usually concern that one of these blood clots will break off and travel through the blood stream into the heart or lungs. Were this to happen, the embolus could get stuck and prevent blood flow. To prevent this from occurring, an intravascular filter can be inserted into the inferior vena cava to catch any emboli from traveling further.
 
  • 37191, insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
 
The advanced skills of an interventional radiologist are used during many more procedures, including: embolization (uterine fibroid, uterine artery, and/or varicocele), varicose vein treatments, and clearing obstructions from the urinary tract (such as kidney stone fragments).
 
Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Fla., is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com.
 



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