February 28, 2011

ACR Radiology Coding Source™ January-February 2011 Q and A

Q: The Food & Drug Administration recently approved equipment used for digital breast tomosynthesis.  How is digital breast tomosynthesis coded?

A: Currently, there is no CPT code that accurately describes a digital breast tomosynthesis study.   Until a code is created, it would be appropriate to report the unlisted diagnostic procedure code 76499.  It is not appropriate to report a three-dimensional reconstruction code in conjunction with a full-field digital mammography code.

Q: What code should be reported as the primary code during multiple interventions in the same vascular territory when performing lower extremity arterial endovascular procedures?  Is it based on chronology of when interventions are performed, increasing order in the CPT codebook, or intensity as determined by work relative value units (RVU)?  For example, in the tibial/peroneal artery, the atherectomy code has a higher RVU than the stent code.  So if atherectomy is performed in one vessel and stent in another, which is the primary code?

A: For lower extremity arterial revascularization, the choice of the primary code involving multiple interventions in the same vascular territory should be based on the intensity as determined by the relative value units (RVUs).  One should report the highest valued RVU code as the primary code. For example, if a stent is placed in the anterior tibial and an atherectomy performed in the posterior tibial, the atherectomy (37229 – RVU value 14.05) would be the primary code and the stent (37230 – RVU value 13.80)* would be the add-on code.

The introductory notes of the 2011 CPT® codebook, p.208, provide the following coding guidance:

These lower extremity codes are built on progressive hierarchies with more intensive services inclusive of lesser intensive services. The code inclusive of all of the services provided for that vessel should be reported (i.e. use the code inclusive of the most intensive services provided).

The “intensity concept” translates to the RUC value of work and not to the numerical order of the base code in the CPT® codebook. Therefore, the increasing order of intensity for lower extremity arterial endovascular interventions is percutaneous transluminal angioplasty, stent, atherectomy, and stent/atherectomy based on the RUC survey data and the final Centers for Medicare and Medicaid Services work RVU content.

*Errata – The above incorrectly listed the stent add-on code as 37230 with an RVU value of 13.80.  The correct stent add-on code is 37234 at an RVU value of 5.50. [Updated 3/10/11]

Q: Is the imaging of the thoracic spine in AP, lateral, and swimmer’s views considered a two-view or three-view study?

A: Imaging of the thoracic spine in anteroposterior (AP), lateral, and swimmer’s views is considered a three-view study and is appropriately reported by code 72072 (Radiologic examination, spine, thoracic; three views).

Prior to 2001, 72072 described a radiologic examination, spine; thoracic, AP and lateral, including swimmer’s view of the cervicothoracic junction. In 2001, code 72072 was editorially revised to specify the number of views versus the types of views to allow greater flexibility in reporting.  Code 72072 was revised to describe a three-view study.

The swimmer's view is considered a unique view and not simply an additional lateral view. The main difference between the swimmer’s view and other plain views is the way the technologist positions the patient, as both the upper and lower thoracic vertebrae cannot be adequately viewed on the lateral projection. Due to overlying anatomy in the lateral projection (the shoulders), an additional projection (swimmer’s view) with different exposure factors must be done to evaluate the upper thoracic spine. 

It should be noted that when more than one exposure is necessary to obtain complete coverage for a particular view, it is not appropriate to code for more than the single view.