ACR Radiology Coding Source™ November-December 2008 Q and A

Q: Must you have an order from the referring physician that specifically asks for wall motion and ejection fraction in order to perform and report them when only a cardiac stress SPECT or thallium stress SPECT is listed on the order?

A: No, an order that specifically requests the performance of wall motion and ejection fraction studies is not required in addition to a request for a cardiac stress SPECT or thallium stress SPECT study. The performance of wall motion and ejection fraction is part of the test design exception, as codified in the Medicare Carriers Manual Internet Only Manual, Section 80.6.5, which states:

Test Design

Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media).

Q: How is a real-time duplex and color imaging study of the groin to look for a pseudoaneurysm, arteriovenous (A-V) fistula or hematoma reported?

A: Duplex and color imaging of the groin is appropriately reported with code 93926 (Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited). If a duplex and color imaging study is performed as a part of an ultrasound-guided compression repair, report 76936 [Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (including diagnostic ultrasound evaluation, compression of lesion and imaging)].

Q: How should a gastrostomy tube button change that is performed through a mature tract without fluoroscopic guidance be reported?

A: A gastrostomy tube button change that is performed through a mature tract without fluoroscopic guidance should be reported with code 43760 (Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance). When fluoroscopic guidance is used, it is appropriate to report the enteral access code 49450 (Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report) established in 2008.

Q: A referring physician wants to verify that a jejunostomy tube is properly positioned. An un-enhanced CT of the abdomen (diaphragm to the crest) is performed, followed by the injection of 50 mL of air and a repeat non-enhanced CT scan of the abdomen (using the same parameters). What is the appropriate coding for this examination?

A: A noncontrast (un-enhanced) computed tomography of the abdomen, followed by the injection of 50 mL of air, and repeated noncontrast CT imaging of the abdomen is appropriately reported with CPT code 74150 (Computed tomography, abdomen; without contrast material). It is not appropriate to code for a contrast enhanced CT scan because the air injection is not considered sufficient to fulfill the requirements for a contrast study. As always, there needs to be an appropriate medical indication for this examination and an order from the referring physician.

More commonly, evaluation for position of an enteral catheter is done under fluoroscopic guidance and is reported with CPT code 49465 (Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report) which includes the imaging guidance.