ACR Radiology Coding Source™ November-December 2010 Q and A

Q: The radiology department performed a diagnostic solid lesion biopsy using a smaller gauge needle. A small semisolid specimen was obtained. The pathology department processed this as an "aspirate," as there was not enough solid tissue to make a block. Is the radiology department required to report the aspiration biopsy code based upon the pathologist’s processing of the specimen?

A: No, the radiology department is not required to report a biopsy procedure code based upon the way the specimen is evaluated by the pathologist. The selected biopsy code reported by the radiologist should reflect the biopsy technique used for the procedure. Ideally, radiology and pathology should be using consistent terminology; however, there may be circumstances when a core biopsy specimen is sent to pathology for histological evaluation and it may not be possible to process the specimen as intended. As stated in the introductory section of the CPT 2011 codebook, Select the name of the procedure or service that accurately describes the procedure performed, do not select a CPT code that merely approximates the services provided.

Core needle biopsies acquire a core of tissue and are intended for histological evaluation. The core of tissue may be obtained with a needle of any size, such as a small caliber needle or a larger gauge “cutting” needle. Aspiration biopsies may be performed with fine needles or with needles of a larger gauge, but the intent is to obtain only cytologic specimens. Aspirations are usually performed when a fluid-containing structure is sampled, or after the instillation of sterile fluid to facilitate obtaining a specimen.1

Q: How is a percutaneous cholecystostomy reported as of January 1, 2011?

A: As of January 1, 2011, the radiological supervision and interpretation (imaging) performed in conjunction with a percutaneous cholecystostomy procedure is bundled into code 47490. Therefore, it is not appropriate to report 75989 separately. The AMA CPT 2011 Errata notes that the cross-reference (For radiological supervision and interpretation, use 75989) is listed in error in the CPT 2011 codebook.

Q: What supervision level is required for CT and MRI studies?

A: The Centers for Medicare and Medicaid Services require that contrast-enhanced (with contrast) computed tomography (CT) and magnetic resonance imaging (MRI) studies be performed under the direct supervision of a physician. Direct supervision requires that the supervising physician be present in the office suite or facility and immediately available to furnish assistance and direction throughout the performance of the procedure.

The supervision levels for all services are listed in the Medicare Physician Fee Schedule Relative Value Unit file. Supervision levels, as defined in the Medicare Physician Fee Schedule (MPFS), apply to the technical component only.

See the 2011 listing of supervision levels on the CMS website under RVU11A download.

Q: Can you tell me the supervision level required for CPT® code 74230 (Swallowing function, cineradiography/videoradiography). According to the Centers for Medicare and Medicaid Services’ Medicare Physician Fee Schedule, it lists a supervision level of 09 – concept does not apply, as well as a level of 03 - personal supervision. What is the correct supervision level?

A: Supervision levels, as defined in the Medicare Physician Fee Schedule (MPFS), apply to the technical component only. Therefore, be sure to read the technical component (TC) line in determining the type of supervision level required to perform a study. For example, the following is an excerpt from the MPFS listing of supervision levels for 74230:

HCPCS/CPT	MODIFIER	DESCRIPTION	PHYSICIAN SUPERVISION OF DIAGNOSTIC PROCEDURES
74230		Cine/vid x-ray, throat/esoph	09 [Global]
74230	TC	Cine/vid x-ray, throat/esoph	03 [Technical]
74230	26	Cine/vid x-ray, throat/esoph	09 [Professional]

As noted above, the MPFS lists the supervision level for three billing line items: global, technical component, and professional component. A supervision level of “03” for the technical component designates that a personal level of supervision is required for code 74230. According to the Centers for Medicare and Medicaid Services, personal supervision requires the supervising physician to be in attendance in the room during the performance of the procedure. Note that a “09,” concept does not apply, is assigned to the global (no modifier) and professional (modifier 26) components.