April 30, 2006

ACR Radiology Coding Source™ March-April 2006 Q and A

Q: Is it appropriate to code a CTA of the Chest (71275) if only 2-D reconstructions are performed?

A: Yes, it is appropriate to code a CTA of the chest for the detection of pulmonary embolism (PE) if only 2-D reconstructions are performed. CTA includes 2-D or 3-D reconstructions. For nonvascular CT (ie, nonCTA services), 2-D reconstructions are included in the base CT code, however, 3-D renderings are separately coded using 76376 or 76377. 

As noted in the June 2002 ACR Bulletin coding article, "…the acquisition of CTA image data includes skeletal anatomy, soft tissues and vessels. In CTA, typically, a few unenhanced images are taken to calibrate the scanner and localize the anatomic region to be evaluated during the contrast-enhanced scan. The patient is then given a rapid injection of intravenous contrast to enhance the blood vessels. A full set of enhanced CT data is then obtained, which includes all of the anatomy in the area to be examined; an enhanced CT of that region and field-of-view is included in the CTA. Following the imaging, 2-D or 3-D reformatted images are typically performed. The 2-D reformatted images can be created in multiple planes, then interpreted, annotated and archived as hard copy, electronic files or both. The 3-D or volume-rendered reconstructions are typically evaluated in multiple projections. The work of 3-D reformatting is quite extensive, usually performed on a separate work station. Vessels are highlighted and featured for viewing and noncritical areas, such as bony structure and surrounding soft tissues, are eliminated in order to provide a focused evaluation of the vasculature. The entire process, including the acquisition of localizing images and contrast-enhanced data, the reformatting of those images and the interpretation of both the source images and the reconstructions that defines the work of a CTA study and is included in the respective CPT® codes." 

1ACR Bulletin Coding Article, June 2002. 

Q: Is it appropriate to report the fluoroscopic guidance code 76003 with code 20982 when fluoroscopy is used for radiofrequency ablation of a bone tumor code?

A: When the radiofrequency ablation (RFA) of bone tumors was reviewed and presented at the CPT Editorial Panel, it was noted that RFA of bone tumors always was performed with CT guidance. That is why CT guidance was then included in the final code descriptor and used in the Relative (Value) Update Committee (RUC) evaluation and recommendation. 

It is because this code is described and valued as being performed with CT guidance that the ACR recommends that the unlisted musculoskeletal procedure code (20999) and fluoroscopic guidance code (76003) be reported when a bone RFA study with fluoroscopic guidance is performed. The rationale is that 20982 (Ablation, bone tumors [eg, osteoid osteoma, metastasis], radiofrequency percutaneous, including computed tomographic guidance) is accurate only for bone RFA with CT guidance. If a significant use of fluoroscopic or other guidance for this procedure develops (which is believed to be unlikely), then additional codes would have to be created. 

Q: Would the administration of Xanax or chloral hydrate be reported by the new moderate (conscious) sedation codes?

A: It would not be appropriate to report the new moderate (conscious) sedation codes for the administration of Xanax or chloral hydrate. The use of drugs to reduce anxiety or tension is not included in or reported by the new moderate sedation codes. Although oral, rectal and intranasal are listed as possible routes of administration (CPT Changes: An Insider's View 2006, page 272), it would be rare that these routes of administration would be used alone to induce moderate sedation. There may be instances, however, in the pediatric population when an oral medication (such as Versed lollipops) may be used as the sole method to induce moderate sedation. In this case, it would be appropriate to report the new moderate sedation codes if all the other CPT requirements for reporting moderate sedation are met, ie, physician in attendance during the intraservice period of sedation and the presence of an independent trained observer. 

Q: When does the intraservice time begin and end for the new moderate (conscious) sedation codes (99143, 99144, 99145, 99148, 99149, and 99150)?

A: According to the CPT Guidelines, "Intraservice time starts with the administration of the sedating agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation." The new CPT codes for moderate sedation and the corresponding Relative (Value) Update Committee recommended work values require that the physician be in attendance during the intraservice period of sedation. If a drug is administered to accomplish "moderate sedation," then the time claimed by the physician for the moderate sedation codes submitted must correspond to the documented personal attendance by the physician providing the sedation. Note that a physician cannot order that a drug be given and then leave the patient. For example, a radiologist cannot order a medication be given to induce moderate sedation for an MRI study and then leave the patient with a nurse in attendance to monitor the patient status. This does not meet the requirement of continuous face-to-face attendance by the physician.