February 28, 2009

ACR Radiology Coding Source™ January-February 2009 Q and A

Q: How should intrafraction localization used during the delivery of radiation therapy be reported? 

A: If a CT scanogram or topogram of the lower extremities is all that is performed for leg measurement, then this is simply a radiograph performed on a CT scanner and Current Procedural Terminology® (CPT®) code 77073 (Bone length studies, orthoroentgenogram, scanogram) should be reported. In some circumstances, however, a CT examination may be appropriate; for example, when there are flexion contractures that would distort anteroposterior images, and when lateral images from a CT can provide bone leg measurement in patients with leg inequalities (e.g., ununited fracture). These CT studies are performed to determine whether there are rotational components, not to determine whether or how much leg length discrepancy is present. 

When a bilateral CT study of the lower extremities is medically necessary and performed on patients with leg length inequalities, CPT® code 73700 (Computer tomography lower extremity; without contrast material) should be reported once. The contralateral leg is usually studied for comparison purposes and should not be reported separately. 

Q: What code should be used to report a sacroplasty procedure? 

A: New Category III codes 0200T (Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device (if utilized), one or more needles) and 0201T (Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device (if utilized), two or more needles) were posted on the American Medical Association (AMA) Web site in January and will be available for use on July 1, 2009. Until that time, it is recommend that code 22899 (Unlisted procedure, spine) be reported. 

As noted on the AMA Web site, if fluoroscopic or CT guidance is performed in conjunction with sacroplasty, it is appropriate to report 72291 or 72292, as these codes accurately describe the guidance used. According to the AMA, “When reporting codes for services provided, it is important to assure the accuracy and quality of coding through verification of the intent of the code by use of the related guidelines, parenthetical instructions, and coding resources.”1 

1 “Instructions for Use of the CPT® Codebook.” In CPT® 2009 Codebook, Professional Edition, p. xiv, American Medical Association, 2009. 

Q: What is the appropriate coding for a nasogastric placement of an enteroclysis tube? 

A: A small bowel enteroclysis exam, typically, is performed using a tube that is placed into the small intestine either through the nose or through the mouth. Code 44500 (Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure)) describes this exam. Fluoroscopy, the imaging technique used to guide and confirm the placement of the tube, is reported with code 74340 (Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation). When the tube is determined to be in the correct position, contrast (barium) is administered through the tube and into the small intestine. Radiographic images are taken to examine the small intestine for abnormalities. These images are separately reported by code 74251 (Radiologic examination, small intestine, includes multiple serial films; via enteroclysis tube). 

Note that code 74355 (Percutaneous placement of enteroclysis tube, radiological supervision and interpretation) describes a percutaneous placement of an enteroclysis tube and should not be reported for a nasogastric placement of an enteric tube. 

For additional information on the coding and performance of an enteroclysis exam, see Clinical Examples in Radiology, Volume 2, Issue 4, Fall 2006; and the ACR Practice Guideline for the Performance of an Enteroclysis Examination in Adults

Q: How should intrafraction localization used during the delivery of radiation therapy be reported? 

A: Category III code 0197T (Intrafraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment) was posted on the American Medical Association Web site in July 2008 with implementation on January 1, 2009. As noted in the descriptor, this code is used to track the target or patient motion during conformal radiation delivery. 

As noted in the CPT® 2009 Codebook, “Select the name of the procedure or service that accurately identifies the service performed.” Because a Category III code has been established to describe this procedure, it must be reported as it accurately describes the procedure performed. 

Q: Are radiologists required to dictate separate reports when abdominal and pelvic computed tomography scans are performed at the same setting? Does the ACR reference this in the Practice Guideline for Communication of Diagnostic Imaging Findings? 

A: A small bowel enteroclysis exam, typically, is performed using a tube that is placed into the small intestine either through the nose or through the mouth. Code 44500 (Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure)) describes this exam. Fluoroscopy, the imaging technique used to guide and confirm the placement of the tube, is reported with code 74340 (Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation). When the tube is determined to be in the correct position, contrast (barium) is administered through the tube and into the small intestine. Radiographic images are taken to examine the small intestine for abnormalities. These images are separately reported by code 74251 (Radiologic examination, small intestine, includes multiple serial films; via enteroclysis tube). 

Note that code 74355 (Percutaneous placement of enteroclysis tube, radiological supervision and interpretation) describes a percutaneous placement of an enteroclysis tube and should not be reported for a nasogastric placement of an enteric tube. 

For additional information on the coding and performance of an enteroclysis exam, see Clinical Examples in Radiology, Volume 2, Issue 4, Fall 2006; and the ACR Practice Guideline for the Performance of an Enteroclysis Examination in Adults