June 30, 2010

ACR Radiology Coding Source™ May-June 2010 Q and A

Q: Where can I find additional coding tips on how to assign the appropriate CPT code?

A: All coders are instructed to carefully read the Introduction section and specific guidelines provided within each section of the CPT code book.  These sections of the CPT code book provide important information on how to appropriately assign a code, and too many coders fail to review these notes. 

Experienced coders, as well as new coders, are advised to review these basic guidelines yearly, as these guidelines change periodically.  For example, in 2002 theInstructions for Use of the CPT Codebook section was updated to specify that coders are to select the name of the procedure or service that “accurately” identifies the service performed and not to select a CPT code that merely approximates the service provided.  This was a change to the long-standing practice that advised a coder to choose a code that “most accurately” identifies the procedure performed. 

Specific guidelines at the beginning of each section of the CPT code book (eg, Evaluation & Management, Surgery, Radiology, Medicine) help to define when to use the codes within that section.  For example, the radiology guidelines (prior to the 70000 series codes) provide additional information on the definition of separate procedures, unlisted services, supervision and interpretation codes, reports, and the administration of contrast.  In addition, prior to the listing of the specific codes within the radiology section, additional clarification is given (eg, cardiac magnetic resonance imaging and computed tomography guidelines are provided prior to the 75557-75574 codes; diagnostic ultrasound coding guidelines are provided prior to the 76000 series of ultrasound codes).  These guidelines provide important coding details that help the coder determine the appropriate code(s) to choose to describe a particular procedure or service.

Parenthetical statements following a code and descriptor also are provided to prevent errors, but they are not all inclusive.  As noted in the CPT 2010 code book, 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, including CPT Assistantand other publications resulting from collaborative efforts of the American Medical Association with medical specialty societies (eg, Clinical Examples in Radiology).

The AMA CPT code books are updated yearly and available for purchase in October.  Implementation of the new codes and guidelines are effective January 1 of the following year.  Be sure not to overlook these important sections of the CPT code book when reviewing the changes for the year, as they offer important coding tips to both the new and veteran coder.

Question:  Have the Centers for Medicare and Medicaid Services (CMS) changed their guidelines on the chiropractor exemption for plain film x-rays that allows radiologists to order diagnostic tests?

Yes, as noted in the January/February 2008 ACR Radiology Coding Source, CMS no longer has a “chiropractor exception” that allows nontreating physicians, such as radiologists, to order diagnostic tests at a chiropractor’s request to identify a subluxation of the spine.

Prior to January 1, 2000, the law required that an x-ray confirm the subluxation diagnosis for Medicare to reimburse for chiropractic adjustments to correct subluxations. Radiologists, however, did not qualify under Medicare rules as a treating physician, and chiropractors are not permitted to order x-rays. Therefore, the regulations provided a “chiropractor” exception.  In 2000, the law eliminated the requirement for x-ray confirmation of spinal subluxations; however, the chiropractor exception remained in Medicare rules for eight years. In 2008, CMS acted to align its reimbursement policies with the 2000 statutory change. Consequently, CMS no longer pays for x-rays or other diagnostic tests ordered by a nontreating physician to be used by chiropractors to demonstrate subluxation.

The following language is stated in the Medicare Benefit Policy Manual, Chapter 15 §240.1

Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor’s order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services.”