CCI Comment Letter re: Appropriate Coding of CT and MRI When Performed on Adjacent Anatomic Areas
July 3, 2003
Niles Rosen
Medical Director
National Correct Coding Initiative
AdminaStar
8115 Knue Road
Indianapolis, IN 46250-1936
Re: CCI Issue Regarding the Appropriate Coding of CT and MRI When Performed on Adjacent Anatomic Areas (CMS letter dated May 1, 2003)
Dear Dr. Rosen:
The American College of Radiology (ACR) appreciates the opportunity to comment on the appropriate coding of CT and MRI scans on adjacent anatomic areas. The ACR has reviewed the CMS letter dated May 1, 2003 regarding an individual’s concerns over what they feel is inappropriate coding of CT and MRI procedures. Since there are many instances where it is medically necessary and clinically indicated to perform CT or MRI scans on adjacent anatomic areas, the ACR is concerned that what may be identified by one individual as inappropriate coding, may well be correct coding, based on clinical indications and medical necessity.
The multiple procedure reduction rules apply mainly to procedures in the surgical section of CPT. The ACR agrees with this concept and radiologists who use these codes (e.g. angiography procedures) are subject to these reductions as there is demonstrated economy with the second and additional procedures that warrant the reductions. By CPT coding convention, the multiple procedure reduction rules were never intended to be applied to radiology services. This is due to the fact that interpreting examinations of different anatomic areas on the same patient does not have the same economy, as do multiple procedures on that patient. In fact, interpreting multiple exams on the same patient often increases the work, as a finding on one exam may necessitate re-evaluation of the first exam looking for an associated finding. In your example of the CT abdomen and pelvis, if the radiologist finds an abnormal lymph node on the pelvis CT, they will need to re-examine the abdomen CT a second time to ensure that no abnormal lymph nodes exist there.
According to ACR’s Practice Guidelines and Technical Standards, interpretations of radiology imaging procedures are separately, identifiable full services. The ACR’s guidelines for CT and MRI studies require documented procedures and technical factors to be prepared by each anatomic site. According to the guidelines, the physician has the responsibility for all aspects of these studies including but not limited to: reviewing all indications for the examination, specifying the pulse sequences to be performed, specifying the use and dosage of contrast agents, interpreting images, generating written reports, and assuring the quality of both the images and interpretations.
As for the example of a patient with a problem at T12/L1, these are two separate, albeit contiguous, anatomical regions and it would be entirely appropriate to code for a CT of the thoracic spine and a CT of the lumbar spine. These are NOT "one CT scan" any more than if a CT examination were performed at two non-contiguous areas such as a CT examination of the cervical and lumbar spine. To the extent that the individual CT scans in the example were "limited" in each of the anatomical regions, it would be appropriate to use a –52 modifier. The same holds true if MRI is used instead of CT.
CT of the head or brain (70450-70470) has been a source of confusion in that the descriptor is anatomically imprecise. It should be CT of the cranial vault or brain. Typically, this series of sections obtained for this study start at the base of the brain or skull and extend cranially to and through the vertex of the skull. Maxillofacial structures such as the ethmoid and sphenoid sinuses, and orbits are only partially included, if at all. The maxillary sinuses, nasal cavity, nasopharyngeal and oropharyngeal structures, the maxilla and mandible, and the temporo-mandibular joints are never included in a CT of the brain and are coded separately when examined. The same is true for MRI of the brain as opposed to MRI of the orbits, face and neck. The descriptor for MRI of the brain, fortunately, is more precise than the analogous descriptor for CT of the brain in that the layman’s term "head" was properly omitted. In addition, the slice thickness and plane of acquisition for the separate anatomical structures is frequently different. For example, CT exams of the brain, though acquired in an axial plane, are angled relative to the true zero degree transaxial plane to optimize visualization of the brain tissue and minimize artifact from the skull base bony structures. CT of the sella turcica, sinuses and facial bones often require coronal plane imaging. CT of the neck is most often acquired in the true transaxial plane.
The ACR strongly advocates appropriate CPT coding. The ACR remains supportive of educating physicians of correct coding through AMA resources, as well as ACR resources, and firmly believes that this type of coding information is the best method in achieving accurate coding.
The ACR appreciates this opportunity to provide input on appropriate coding for CT and MRI when performed on adjacent anatomic areas. It is important that the ACR and CMS continue to work in a joint effort to maintain and strive for accurate coding and implementation of accurate CCI edits. Because the ACR views this as an important issue, we would like to initiate a conference call with CMS and AdminaStar. Kim Longworth can be contacted at 1-800-227-5463, ext. 4960 or email kiml@acr.org to facilitate in the setting up of a conference call.
Sincerely,
Gordon S. Perlmutter, MD, CPT Advisor, ACR Chairman, ACR Committee on Coding and Nomenclature
Kim Longworth, Analyst, Economics and Health Policy
cc: Marsha Mason-Womsley
Linda Dietz
William T. Thorwarth, MD
Barry D. Pressman, MD
John A. Patti, MD
Pamela J. Kassing
Diane Hayek
