August 31, 2006

ACR Radiology Coding Source™ July-Aug 2006 Q and A

Q: When a CT angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff study (75635) is performed, must the radiologist mention in his or her report the evaluation of the entire abdominal aorta (not just the distal portion), as well as the bilateral femoral vessels (not just the external iliac arteries)?

A: When a CT angiography of the abdominal aorta and bilateral iliofemoral lower extremity runoff study (75635) is performed, the entire abdominal aorta, which means up to the diaphragm, need not be reported. The CTA of the abdominal aorta, like conventional angiography, should be tailored to the individual patient and clinical indication. In most circumstances, this includes imaging of the abdominal aorta just above the level of the renal arteries and imaging inferiorly. It would be quite unusual to include the abdominal aorta up through the diaphragmatic hiatus.

When an abdominal aorta and bilateral iliofemoral lower extremity runoff study is performed, the evaluation also should include both the iliac and femoral arteries in the lower extremities at least to the level of the knees and usually to the level of the ankles.

Q: How do you code for ankle/brachial indices with a duplex scan of the lower extremity arterial bilateral blood flow study? Can both studies be coded when performed at the same time? Can color flow velocity mapping also be charged if performed?

A: When a duplex Doppler of the lower extremities is performed with the addition of ankle/brachial (A/B) indices, it is appropriate to code 93925 (Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study) for the duplex scan and 93922 (Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (eg, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) for the A/B indices.

Code 93922 is for a limited noninvasive physiologic arterial study that covers one level only of each leg (eg, ankle brachial indices with ankle waveforms).1 It is not appropriate to code 93922 in conjunction with 93923 (Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethsmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia) as 93922 is a limited version of 93923. Code 93923 includes segmental pressures and tracings and is used to report bilateral complex noninvasive physiologic testing procedures.

Duplex scanning (such as 93925) describes an ultrasonic scanning procedure for characterizing the pattern and direction of blood flow in the arteries in a single display of real time images integrating 2-D vascular structure with spectral and color flow Doppler mapping or imaging.

As noted in the CPT 2006 codebook, the noninvasive physiologic studies are performed using equipment separate and distinct from the duplex scanner. Codes 93875, 93965, 93922, 93923, and 93924 describe the evaluation of nonimaging physiologic recordings such as ankle/brachial indices, Doppler analysis of bidirectional blood flow, plethysmography, and/or oxygen tension measurements appropriate for the anatomic area studied.

Q: How should an MRI of the abdomen performed in conjunction with an MRCP study be reported?

A: If imaging of the abdomen is performed concurrently with a magnetic resonance cholangiopancreatography (MRCP) study, it is appropriate to report one of the MRI of the abdomen codes (74181, 74182, or 74183) plus a 3-D reconstruction code (76376 or 76377). An additional MRI of the abdomen code should not be reported, as performance of an additional sequence or two would be considered part of the base procedure code.

A magnetic resonance cholangiopancreatography (MRCP) study includes MIP cholangiographic images, as well as any axial and/or coronal abdominal MR cross-sectional images.

Q: We perform 5 mm cuts of the abdomen and of the pelvis using CT without contrast to diagnose kidney stones and ureteral stones. How should this be reported?

A: If CT without contrast studies of the abdomen and pelvis are performed to detect kidney stones or ureteral stones, it is appropriate to report both a CT of the Abdomen code (74150) and a CT of the Pelvis code (72192) as these codes accurately describe the procedure performed. Please refer to the December 1996 ACR Bulletin coding article and CT Practice Guideline on Performance of CT Abdomen and CT Pelvis for a discussion on the appropriateness of performing and reporting a CT abdomen and CT pelvis studies.