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2006 CPT® Code Update

There are many changes to CPT® 2006 that will affect radiology. The most significant changes include: the addition of 2 new 3-D image rendering codes, the deletion of the reconstruction code 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computed tomography, magnetic resonance imaging, or other tomographic modality), and the addition of 8 new Category III codes used to report cardiac computed tomography (CT) and computed tomographic angiography (CTA). This article will discuss those changes as well as others for 2006 that include new codes to describe mechanical thrombectomy, removal of ureteral stents, radiofrequency ablation of renal tumors, endovascular repair of the descending thoracic aorta, intracranial angioplasty, stenting and dilatation, stereoscopic x-ray guidance, and neutron therapy.

Diagnostic Radiology

New 3-D Rendering Codes

Currently, 2-D and 3-D postprocessing is reported with CPT® code 76375. In 2006, this reconstruction code will be deleted and replaced by 2 new 3-D rendering codes. These 3-D rendering services will be differentiated by those studies in which reformatting is performed on the acquisition scanner (76376) from those where reformatting is performed on an independent workstation (76377).

The distinction between these 3-D rendering codes is the difference in work involved and the role of the interpreting physician. For example, 3-D ultrasound units are primarily software-driven and do not require independent workstation reconstruction, as does the more complicated CT work that tends to be a more extensive procedure. For the 3-D reconstructions not requiring image post-processing on an independent workstation, the physician will discuss with the technologist the need for 3-D imaging and supervise the technologist in creating 3-dimensional images. For studies performed on an independent workstation, the physician will supervise and/or create the 3-D reconstructions and adjust the projection to optimize visualization of anatomy or pathology.

The new 3-D codes will require concurrent physician supervision of image post-processing, 3-D manipulation of volumetric data set and image rendering.

Although a parenthetical statement following these new codes specifies the list of codes (computed tomographic angiography, magnetic resonance angiography, positron emission tomography, CT colonography) with which these procedures should not be reported, it should be noted that this listing is incomplete. A clarification will be made in a future CPT Assistant article and to the CPT® code book to note that you should not report 76376 or 76377 in conjunction with any of the Nuclear Medicine codes (78000-78999), or with the new Category III cardiac CT and CTA codes.

All 2-D reconstructions will be considered part of the base procedure code and will not be reported separately as of January 1, 2006.

Reasons for Change

The principal reason for the reconstruction coding revisions was the technological advancement in post-processing and the ease of creating 2-D reformatted images (eg, sagittal, coronal, multiplanar, oblique). This had resulted in a marked increase in use and perceived overutilization of the reconstruction code 76375. According to the 2004 Medicare Part B Physician Supplier Procedure Summary report for non-managed care beneficiary claims, the reporting of 76375 increased a total of 62% between 2003 and 2004 and a total of 281% from 2000 to 2004. Most of this increase was in the simple 2-D reformats. Because of this marked increase in utilization, CMS proposed to implement National Correct Coding edits on the use of 76375. However, at the request of the ACR, CMS agreed to postpone the implementation of edits with the expectation that a code change, to incorporate 2-D reformatting into the base procedure code, would be requested by the ACR. This revision of the reconstruction code averted universal CCI edits that would have otherwise been put in place on 76375, thereby eliminating payment for all types of 2-D reformatting and 3-D rendering.

In addition, code 76375 no longer adequately describes the complex reformatting that is now performed for 3-D rendering, which includes shaded surface rendering, volumetric rendering, maximum intensity projections, fusion of images from other modalities and quantitative analysis. With the advancement of technology, 3-D rendering has become more complex and often requires independent workstation processing by a radiologist or a specially-trained technologist. Conversely, since the advent of spiral CT, 2-D reformatting of a digital image now can be performed by a technologist at the push of a button, without the need for a separate workstation or the need to take the scanner offline.

Reference the July 1999 ACR Bulletin coding article titled Code 76375 and Coding Issues for historical background on the use and development of 76375.

New CPT Category III Codes Describe Cardiac Computed Tomography and Computed Tomographic Angiography

The American College of Radiology, the American College of Cardiology and the Blue Cross and Blue Shield Association worked in a collaborative effort to create a coding structure that allows for the accurate reporting of all combinations of cardiac CT and CTA studies performed today. Eight new Category III codes have been developed to report cardiac CT and CTA used to evaluate coronary artery calcification, cardiac structure and morphology, cardiac function and coronary vasculature. Various permutations of studies currently being performed are described by these codes, which will allow for more accurate reporting of the work involved. Data collected by tracking these codes will help determine what will be included in the eventual development of Category I codes for reporting cardiac CT and CTA.

Early in the evolution of cardiac CT and CTA, the ACR recommended that the CTA of the chest code (71275) be reported. However, it is now apparent that the CT techniques for high-quality coronary CTA are vastly different from the examinations described by 71275. The CTA of the chest code was originally developed and valued for imaging of non-coronary thoracic vessels. It was not valued to address the evaluation of coronary arteries, calcium scoring or structure and function of the heart.¹ The performance of a cardiac CT and CTA differ greatly from CTA of the chest with regard to physician and technical work that includes scanning protocols, data acquisition, software used, post-processing analysis and interpretation.

Currently, unless specific payers have instructed otherwise, the ACR recommends reporting the unlisted CPT® code 76497 for cardiac CT and CTA studies. As of January 1, 2006, the following Category III codes must be used to report these studies since they accurately describe the procedures performed:

Code 0144T is used as a stand-alone code when only a calcium score is ordered or when such a volume of calcium score is identified that the remainder of the intended cardiac imaging evaluation is not performed. When calcium scoring is performed in addition to one of the other cardiac CT and CTA procedures, it is not separately reported, as this service is included in the pertinent procedure codes (0147T or 0149T).

At any given patient encounter, only one of the primary codes (0145T-0150T) is used to describe the combination of cardiac CT and CTA studies performed. Because function will only be done in conjunction with one of these other services, when cardiac function evaluation (ventricular function, ejection fraction and wall motion) is performed, it is reported as an add-on procedure (+0151T) in conjunction with one of the primary procedures (0145T-0150T) and is never reported as a stand-alone procedure.²

See the AMA/ACR Clinical Examples 2nd Interim Bulletin due out in late November for additional discussion of the new cardiac CT and CTA codes, and go to the AMA Web site for a detailed listing of the new Category III code descriptors and cross-references.

¹Coronary Computed Tomographic Angiography, ACR Radiology Coding SourceTM, Jan/Feb 2005.
²AMA/ACR Clinical Examples 2nd Interim Bulletin , November 2005.

Interventional Radiology

Mechanical Thrombectomy

Five new mechanical thrombectomy codes have been added for 2006. Codes 37184-37188 were created to describe nondialysis mechanical thrombectomy for peripheral arterial and venous interventions. The arterial mechanical thrombectomy codes (37184, 37185, 37186) differentiate primary from secondary (eg, embolization as a result of PTA) procedures. The venous mechanical thrombectomy codes (37187, 37188) differentiate a procedure performed as the only intervention in the treatment of a venous thrombus or one provided in conjunction with thrombolytic infusion therapy from a procedure that describes a repeat venous mechanical thrombectomy during a course of thrombolytic therapy.

37184 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel

+37185 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family

+37186 Secondary percutaneous transluminal thrombectomy (eg, non-primary mechanical, snare basket, suction technique) arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy

37187 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance

37188 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy

In addition to the explicit code descriptors, the CPT® 2006 code book provides detailed coding guidelines before the transcatheter procedure section outlining how to use these procedure codes. The guidelines specify that codes for catheter placement(s), diagnostic studies and other percutaneous interventions (eg, transluminal balloon angioplasty, stent placement) provided are separately reportable.

For these mechanical thrombectomy codes, supervision and interpretation is included in the procedure code and is not reported separately using a 70000 series code. Note that while the mechanical thrombectomy codes all include intraprocedural thrombolysis (eg, a tPA bolus of short infusion), they do not include prolonged infusions (eg, sending the patient to the ICU with a tPA drip). When prolonged infusions are necessary and also performed, these are coded separately as 37201 (Transcatheter therapy, infusion for thrombolysis other than coronary) and 75896 (Transcatheter therapy…radiological supervision and interpretation).

Central Venous Access (CVA) Device Check

Code 36598 (Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report) has been added to identify contrast injection(s) given for radiologic evaluation of the position and functioning of an existing CVA device and those structures in close proximity, such as the vena cava. Code 36598 does not describe a complete diagnostic study of the vena cava or extremity veins. When a complete diagnostic study of the vena cava and/or extremity veins is performed, it should be reported with the specific diagnostic venography code (75820, 75825, or 75827). Code 36598 includes the use of fluoroscopy; therefore, fluoroscopy is not reported separately when used. However, when a CVA device is checked fluoroscopically and no contrast injection is performed, then it is appropriate to report the fluoroscopy code 76000 in place of the injection code 36598.

Do not report the mechanical removal of obstructive material codes (36595, 36596) in conjunction with code 36598. When obstructive material is removed from a CVA device during a catheter check, the mechanical removal of obstructive material code 36595 or 36596 should be reported in place of the catheter check code.

Ureteral Stent Removal

A number of different codes (such as endoscopy, nephrostomy, cystourethroscopy, ureterostomy) are being used to describe the exchange of a ureteral stent depending on the approach used. These codes include use of endoscopy, but endoscopy may not be needed and may not be used for many ureteral stent exchanges. Therefore, 4 new codes have been created to identify these procedures via a percutaneous approach and classified by type of catheter placed (indwelling vs externally accessible) and type of procedure performed (removal vs removal and replacement).

50382 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation

50384 Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation

50387 Removal and replacement of externally accessible transnephric ureteral stent (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation

50389 Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent)

The radiologic supervision and interpretation imaging and moderate sedation (conscious) are not coded separately since these are included in the codes. Note that when a ureteral stent is removed without the use of guidance, the removal of the stent is considered part of the evaluation and management service provided and is not reported separately.

Specific codes describing ureteral stent removal from a transurethral approach have not been created as yet and are pending further discussion with the American Urological Association.

Percutaneous Radiofrequency Ablation of Renal Tumor(s)

CPT® code 50592 has been added to CPT® to report percutaneous radiofrequency ablation of 1 or more renal tumors. Creation of this code expands the reporting of percutaneous radiofrequency ablation to a new anatomic site and tumor type that is not currently described in CPT. The image guidance and monitoring during the procedure is reported separately by the existing codes 76362 (CT), 76394 (MR), 76940 (ultrasound) depending on the type of guidance provided.

A category III code (0135T) was established to describe the percutaneous cryotherapy ablation of renal tumor(s) since this technology has not yet met the requirements of a Category I code.

Endovascular Repair of a Descending Thoracic Aortic Aneurysm

Category III codes 0033T-0040T used to describe endovascular repair of a descending thoracic aortic aneurysm have been converted to Category I codes for 2006. The 4 new radiological supervision and interpretation imaging codes (75956, 75957, 75958 and 75959) should be used in conjunction with the 7 new procedure codes (33880, 33881, 33883, 33884, 33886, 33889, and 33891).

Intracranial Angioplasty, Stenting, and Dilatation

Five new codes were developed to describe percutaneous intracranial balloon angioplasty (61630), stenting (61635) and balloon dilatation (61640, 61641, 61642) procedures that are used in the treatment of cerebral circulation problems. Note that a cross-reference following the balloon dilatation codes clarifies that "61640, 61641, 61642 include all selective vascular catheterization of the target vessel, contrast injection(s), vessel measurement, roadmapping, postdilatation angiography, and fluoroscopic guidance for the balloon dilatation."

Percutaneous Vertebral Augmentation (Kyphoplasty)

Three procedural codes have been added to describe the performance of percutaneous vertebral augmentation including cavity creation (eg, kyphoplasty). Code 22523 describes the augmentation of a thoracic vertebral body, 22524 a lumbar vertebral body, and 22525 each additional thoracic or lumbar vertebral body. Codes 76012 and 76013, which currently describe the radiologic supervision and interpretation for percutaneous vertebroplasty, have been revised to also include the imaging performed for percutaneous vertebral augmentation.

Exchange of Catheter during Thrombolytic Therapy

CPT® codes 37209 and 75900 (Exchange of previously placed arterial catheter during thrombolytic therapy…) were editorially revised to include the term "intravascular." This change makes it clear that this code can be used to describe either an arterial or venous catheter exchange.

Radiation Oncology

Look for 3 new codes to be added to the radiation oncology section of CPT® 2006.

Stereoscopic X-ray Guidance

CPT® code 77421 (Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy) was developed to report stereoscopic guidance to detect deviations between the actual and the planned target position for the delivery of radiation. By precisely determining the target for the delivery of radiation on orthogonal xrays, healthy tissues that surround a tumor or lesion are spared. Note that taking of a port film (77417) does not describe this process, as a port film is reported once per week for setup corrections alone, not for internal organ motion between fractions of treatment. This new code will be used to report stereoscopic guidance for many anatomic sites which include the lung, brain, head, and neck.

Neutron Radiation Treatment Delivery

Neutron radiation treatment delivery codes 77422 (single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking) and 77423 (one or more isocenters with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)) were developed to report the delivery of high energy neutron therapy which is used in the treatment of radioresistant tumors such as those located in the salivary glands, head and neck. Currently neutron therapy is being reported with codes 77412-77416 (Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam [eg, electron or neutrons]) which are broken out by energy level. However, the costs to deliver neutron therapy are significantly higher than those costs to deliver photon or electron therapy. The differences between neutron therapy and linear accelerator-based treatment (photons and electrons) are evident in the cost of the equipment and non-physician personnel required to deliver the treatment. The establishment of separate neutron therapy codes allows for this differentiation in costs.

Because CPT® codes 77412-77416 will no longer describe neutron therapy, the descriptor will be revised to read Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam...

Although neutron therapy has developed over the past 25 years and there is a body of literature, there are at this time only a few functioning centers which deliver this treatment.

Nuclear Medicine

Cardiac Blood Pool Imaging

Some providers have misinterpreted the appropriate use of the cardiac blood pool imaging add-on code +78496; therefore, a notation has been added to clarify its use. Code +78496 was developed as an add-on code specifically for right ventricular ejection fraction, and is to be used only in conjunction with 78472 in the evaluation of patients primarily with known or suspected pulmonary disease.

Deletions

Effective January 1, 2006 CPT® codes 78160, 78162, 78170, 78172 (radioiron and chelatable blood studies), as well as 78455 (venous thrombosis study), will be deleted since these studies are no longer in use or have become obsolete.

Other Category III Codes

Ablation of Fibroadenomas

Code 0120T (Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma) was created to describe an ultrasound-guided cryosurgical ablation of a fibroadenoma in the breast. A Category III code was created due to lack of wide experience and relatively limited clinical availability of these services at this time. Note, this code does not describe cryolocalization of a fibroadenoma. An unlisted procedure code should be used to describe cryolocalization of a fibroadenoma at this time.

Add-on code +0152T (Computer aided detection…chest radiographs) has been created to be used in conjunction with the existing routine chest radiograph codes 71010, 71020, 71021, 71022, and 71030. Report 0152T in addition to one of the chest codes when CAD is used to aid in identifying suspected nodule sites.

Two codes (0153T and 0154T) were added to describe a transcatheter placement of a wireless physiologic sensor and a noninvasive physiologic study of an implanted wireless pressure sensor, respectively, in an aneurysmal sac during endovascular repair.

See the AMA web site for a listing of the new Category III codes approved by the CPT® Editorial Panel (http://www.ama-assn.org/ama/pub/category/3885.html).

Information on CPT® Category III Codes

Category III codes are used primarily for tracking new procedures and are NOT referred to the AMA Relative Value Update Committee for valuation. However, they are carrier priced if the service is covered.

Updates are posted biannually (January and July) and are effective six months after posting. This delay provides time for providers/payers to update systems. These codes are maintained until they meet Category I code requirements or they are archived after 5 years unless a further need is demonstrated to maintain the Category III code status. For more detailed information on CPT® Category I, II and III codes, go to the AMA web site at http://www.ama-assn.org/ama/pub/category/12886.html.

It is important that your practice have all billing systems updated and new codes available for use when these codes become valid on January 1, 2006. The Health Insurance Portability and Accountability Act (HIPAA) transaction and code set rules require the use of the medical code set that is valid at the time the service is provided. Physicians, carriers and intermediaries no longer have a 90-day grace period to implement new code sets. Reference the ACR Web site at http://www.acr.org/s_acr/doc.asp?CID=3323&DID=19843 for additional information on this HIPAA requirement.

For a complete listing of CPT® Category I, II, and III codes for 2006, please refer to the CPT 2006 code book.