October 31, 2007

ACR Radiology Coding Source™ Sept-Oct 2007 Q and A

Q: Measure #10 of the Physician Quality Reporting Initiative (PQRI) is used to identify patients who have had computed tomography (CT) or magnetic resonance imaging (MRI) studies of the brain performed with a diagnosis of transient ischemic attack (TIA) or intracranial hemorrhage that includes documentation of the presence or absence of hemorrhage, mass lesion, and acute infarction. When the radiologist’s final impression is normal or not TIA, can the ICD-9 code for TIA (435.9) be reported if the referring physician lists a clinical diagnosis of TIA?

A: Per the American Hospital Association’s Central Office, if a patient is seen with signs and symptoms that are an integral part of a TIA or the referring physician makes a clinical diagnosis of TIA, the radiologist may code TIA even though the CT or MRI study is found to be normal. The Central Office refers to the ICD-9-CM Official Guidelines for Coding & Reporting (October 2007), B. General Coding Guidelines, items #6 and #7 that clarify this point (p. 10). 

#6. Signs and symptoms: 
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable 
for reporting purposes when a related definitive diagnosis has not been established 
(confirmed) by the provider. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill- 
Defined Conditions (codes 780.0–799.9) contain many, but not all, codes for 

#7. Conditions that are an integral part of a disease process: 
Signs and symptoms that are associated routinely with a [October 2007 change] 
disease process [such as TIA] should not be assigned as additional codes, unless 
otherwise instructed by the classification.

Therefore, it would be appropriate to report 435.9 as the primary diagnosis to describe a TIA if the clinical history provided by the referring physician is TIA and the CT or MRI study is normal. 

Clearly, the least problematic way to code for a TIA is for the referring physician to use that code without qualifiers such as “rule out, possible, probable, consistent with, etc.” when ordering the study. The diagnosis of TIA can certainly be made on clinical criteria similar to a diagnosis of pneumonia prior to the performance of an imaging study. This clinical diagnosis of TIA provided by the referring physician can be reported as the ICD-9 code for the CT or MRI of the brain study when a more specific diagnosis is not derived from the imaging study (eg, intracerebral hemorrhage). 

However, if all that is given by the referring physician are signs and symptoms as an indication for the CT or MRI examination, then these codes must be carried forward if nothing more specific is derived from the imaging examination (ie, the study is normal). 

The list of eligible codes currently included in Measure #10 will be reviewed by the Centers for Medicare and Medicaid Services and the American Medical Association Consortium Stroke Workgroup for possible expansion in the 2008 PQRI program. 

Q: We are able to provide a detailed 5-mm MRI scan with three different sequences that cover the head to the feet. This study is used to evaluate patients with metastases or lymphoma. How should this study be reported? 

A: A whole-body diagnostic MRI study is rare, and there is no CPT code that accurately describes this procedure. When medically necessary and performed, the unlisted MRI code 76498 (Unlisted magnetic resonance procedure [eg, diagnostic, interventional]) should be reported. When only one or a few discrete anatomical areas are targeted for MRI evaluation, then those specific anatomical regions should be coded. 

Q: How should an order for an ultrasound of the kidneys be performed and coded? 

A: Unless the referring physician specifically asks for a renal size assessment only, we evaluate for an intrarenal or postrenal cause of the patient’s symptoms. Our standard scanning protocol involves images of the kidneys and bladder and often evaluation for ureteral jets within the bladder. This leads me to believe, therefore, that we should actually bill for a complete retroperitoneal ultrasound. 

Radiologists should always tailor their examinations on the basis of the clinical information received, and services should be coded on the basis of both medical necessity and the details of the examination performed. 

According to Current Procedural Terminology® (CPT) guidelines, p. 248 of the standard version of the CPT code book: A complete ultrasound examination of the retroperitoneum (76770) consists of real-time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality. Alternatively, if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound. 

Therefore, if only the kidneys are medically indicated and evaluated, then a limited retroperitoneal code, 76775, should be reported. 

Q: When should CPT code 77084 (Magnetic resonance [eg, proton] imaging, bone marrow blood supply) be reported? Can it be reported in conjunction with joint and spine imaging when FAT suppression techniques (eg, chemical FAT SAT or STIR) are used? For example, if an ankle (73721) study is performed with multiple extra FAT SAT and STIR sequences, can 77084 also be billed? 

A: Code 77084 (Magnetic resonance [eg, proton] imaging, bone marrow blood supply) is a stand-alone code used for a bone marrow survey. It should not be used as an add-on code to describe extra sequences, such as for multiple extra FAT SAT (specialized technique that selectively saturates fat protons prior to acquiring data as in standard sequences) and STIR (short inversion time inversion recovery) sequences. Extra sequences are part of some exam protocols and do not justify an additional CPT code.