April 30, 2007

ACR Radiology Coding Source March-April 2007 Q and A

Q: In the November/December 2006 ACR Radiology Coding Source and in the March 2007 ACR Bulletin, it states that it is appropriate to report 3-D rendered angiography images using codes 76376 and 76377 when performed in addition to the base angiography procedure code. Please clarify this statement as this appears to be contradictory to what has been published previously by the ACR and AMA.

A: The statement that it is appropriate to report the 3-D angiography reconstruction images using codes 76376 or 76377 in addition to the base angiography procedure code is not contradictory to prior coding guidance published by the ACR and AMA. This statement is referring to the reporting of 3-D imaging when performed in conjunction with catheterangiography. It does not refer to the reporting of 3-D with computed tomography or magnetic resonance angiography, where the 3-D rendering is incorporated into the base CTA and MRA codes.

Q: Is the selective catheterization and embolization of the ovarian arteries performed during a uterine fibroid embolization (UFE) procedure coded separately?

A: The selective catheterization and embolization of an ovarian artery during UFE is not coded separately, as it is included in the all-inclusive UFE code 37210.

According to the AMA's CPT® Changes 2007: An Insider's View (p. 114) the following describes the physician work of a UFE procedure:

Local anesthesia is applied to the entry site. The femoral artery is punctured and the sheath placed. A guidewire is advanced over the branch of the aorta into the contralateral uterine artery (or from a second puncture of the contralateral femoral artery, again advancing over the branch of the aorta). An arteriography is performed to provide a road map of the blood supply to the uterus and fibroids. The technical personnel are directed throughout the procedure. An interpretation is prepared of the imaging of all views necessary of the vessels traversed and treated, including the ovarian arteries. The diagnostic catheter is removed, the hydrophilic wire is advanced, and the selective catheter is placed. Under continuous fluoroscopic imaging, particles of embolic material are injected slowly into the flow in the vessel(s) feeding the fibroid. A conformational arteriography is performed and reviewed to ensure that the vessel is blocked with an assessment of the maintenance of the flow to the normal portions of the uterus. Once one side is completed, the other side is embolized. The guiding sheath/catheter is removed from the pelvic arteries. The guiding sheath/catheter is removed from the puncture site. Compression is applied to the puncture site for closure.

CPT® code 37210 (effective January 1, 2007) is inclusive of all services occurring on the day of the procedure as noted in the descriptor.

37210 Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure.

(37210 includes all catheterizations and intraprocedural imaging required for a UFE procedure to confirm the presence of previously known fibroids and to roadmap vascular anatomy to enable appropriate therapy)

(Do not report 37210 in conjunction with 36200, 36245-36248, 37204, 75894, 75898)

(For all other non-central nervous system (CNS) embolization procedures, use 37204)

Q: Is it appropriate to report a diagnostic breast MRI twice when a diagnostic breast MRI is performed on one day, followed by an MRI-guided breast biopsy procedure on the following day?

A: No, it is not appropriate to report a diagnostic MRI study code twice when a diagnostic MRI study is performed on one day, followed by an MRI-guided biopsy study on another day. CPT® codes 77058 and 77059 (formerly 76093 and 76094) are diagnostic MRI breast study codes. The diagnostic MRI code should be reported only once on the day it was performed. Code 77021 (formerly 76393) should be used to report the MRI guidance used for placement of a needle during a breast biopsy procedure. If a diagnostic MRI breast study is performed on the same day as the MRI-guided breast biopsy, it is appropriate to report the diagnostic MRI code and the MRI guidance code, as well as the appropriate surgical code for the breast biopsy.

Q: What is the correct way to bill for a mammography examination on a mastectomy patient when one or two additional films are taken of the axillary region on the mastectomy side? Is it still correct to bill as a bilateral examination even though there is no breast tissue? Is this considered a screening or diagnostic exam?

A: Yes, it is correct to bill a bilateral examination even though there is no obvious breast tissue because both the side of the remaining breast and the mastectomy side are being imaged. This is analogous to a male mammogram, where there is little breast tissue. If there is enough clinical concern to warrant imaging, there is probably clinical concern that a tiny amount of breast tissue remains. This should, therefore, be billed as a diagnostic mammogram.

It is important to note the differences between diagnostic and screening mammography in order to code this procedure correctly. Diagnostic mammography serves a specific clinical purpose in that it is used to diagnose or followup on disease of the breast and to provide additional information about patients who have signs and/or symptoms of breast disease. Screening mammography is used to detect breast cancer in patients who lack signs and symptoms.

A diagnostic mammogram usually includes MLO and CC views as well as other views necessary based on concurrent interpretation to answer the clinical question. Additional views include spot compression, spot compression with magnification, medial-lateral, and tangential views as required. A diagnostic mammogram includes whatever views are needed to evaluate an area of clinical concern. The number and types of views should be identified within the report.1

AMA/ACR Clinical Examples in Radiology, vol.1: 4, Fall 2005.

Q: If a radiologist reviews previous images obtained from another (outside) facility in order to provide an interpretation for a current imaging study, can a separate charge be billed? The previous studies are reviewed for comparative purposes to evaluate any change in the patient's condition.

A: When a radiologist reviews prior images performed either at the same institution or from an "outside" facility at the time he or she interprets an "inside" study, it is not appropriate to code separately for the review of the previous examination. The review of an outside institutional examination is no different from reviewing old inside studies at the time of the interpretation of the new inside service. A comparison with old studies, when available, is an integral part of the interpretation of any study, regardless of where they were performed.