October 31, 2005

ACR Radiology Coding Source™ September-October 2005 Q and A

The following Questions and Answers are presented to highlight some key issues regarding coding and compliance:

Q: When seeing a patient for an ordered ultrasound-guided thoracentesis or paracentesis, is it appropriate to also charge for a limited diagnostic ultrasound of the abdomen or a limited diagnostic ultrasound of the chest, in addition to the charges for the guidance and thoracentesis or paracentesis procedures?

A: Our protocol is to first have the technologist scan all patients to evaluate how much fluid (if any) is present and in which location. The case is presented to the radiologist, who decides on the approach for the procedure ordered. The radiologist then obtains a consent from the patient, rescans the patient to confirm safe needle/catheter access, and then performs the procedure.

No, it is not appropriate to charge for a limited diagnostic ultrasound of the abdomen or a limited diagnostic ultrasound of the chest in addition to the charges for ultrasound guidance during thoracentesis or paracentesis procedures when performed to determine the amount and location of the fluid.

Limited sonography is a necessary component of any ultrasound guidance procedure, just as localizing CT images are a necessary component of CT guidance for CT-guided biopsy. As a reference to what is considered inclusive in imaging guidance, refer to the CPT instructions for new code 76937 (older codes such as 76942 have not yet been updated with this explicit language). Limited sonography of the target area is clearly included in such imaging guidance codes. The introductory language to the ultrasound section in CPT 2005 clearly states that permanent images of the target area are required when imaging guidance is utilized.. The practice of coding for both a limited diagnostic ultrasound and for ultrasound guidance in this instance would constitute unbundling.

There are 2 issues that need to be addressed in the above question: (1) Is this correct coding? (2) Is this, in the eyes of the payer, "medically necessary?"

Is this correct coding?

When image-guided fluid aspiration is requested (eg, for paracentesis or for thoracentesis), and the ultrasound localizing images demonstrate no fluid, then it would be appropriate to code for the localizing limited ultrasound—and only the limited ultrasound—that resulted in the decision to discontinue the requested procedure. For example, because a full chest ultrasound is a fluid search, ultrasound localizing images of the chest would be reported with the ultrasound of the chest code (76604). There is no reason to image all elements required for a full and complete abdomen, therefore, ultrasound localization images of the abdomen would be reported with the limited ultrasound of the abdomen code (76705).

This is analogous to the CMS directive that any medically necessary preliminary or scout studies performed prior to the cancelled order should be coded. For example, as clarified in section 15021 (E) of the Medicare Carrier's Manual, if a barium enema cannot be performed because of residual stool in the colon as identified on scout KUB. The scout KUB is payable by Medicare. When one attempts to perform a service and is unsuccessful, but in the attempt has performed a lesser service, then the lesser service should be reported. (1)

In the scenario where ultrasound guidance is commenced and the thoracentesis or paracentesis is prematurely discontinued (eg, the patient goes into shock), the ultrasound guidance should be coded as 76942 and the thoracentesis (32000-53) or paracentesis (49080-53) should be reported with the discontinued modifier (53).

Is this, in the eyes of the payer, "medically necessary?"

Depending upon the site of service (hospital vs nonhospital), additional nonordered imaging cannot be performed unless it falls into very specific and explicit safe harbors. For example, reference Medicare's Ordering of Diagnostic Tests rule (Medicare Carriers Manual 15021, Transmittal 1725) [LINK]. The performance and coding of an additional limited diagnostic ultrasound study clearly does not meet those criteria in a nonhospital setting. In a hospital setting, the answer is less clear, but a conservative interpretation would indicate that this is problematic as well.

Although the specific clinical service is different, it is felt that these 2 issues (performance of additional procedures and medical necessity) are fundamental ones used by the U.S. Department of Justice in its legal proceedings against a large practice in Florida. The details of that case are sealed, but what the DOJ has released to the public indicates that issues of "unbundling" and "churning" will not be tolerated. That group settled the suit for $2.4 million!

If a radiology practice discovers that it has inadvertently submitted claims with incorrect coding, the practice is encouraged to work with their compliance officers and counsel to determine what funds need to be returned to patients and payers. The Department of Justice and defense counsel in several health care fraud cases tend to look favorably upon honest mistakes when prompt restitution is made.

These types of fundamental questions suggest that a group may benefit from internal or outsourced coding expertise. If radiology certified coders (RCCs) are not employed or contracted, the radiology group is strongly encouraged to do so. An audit of coding practices by an expert in these matters might be of value, as well as ensuring full compliance with coding rules and regulations.

(1)Interventional Radiology Coding User's Guide 2005, Frequently Asked Questions, p.230.

Important Links

Radiology Business Management Association (RBMA)
Radiology Coding Certification Board (RCCB)


Duszak R. Coding Certification: Can you afford less? J Am Coll Radiol. March 2005;2(3):282-283.

Avoiding fraud and abuse issues in radiology. ACR Bulletin. July 2003;59(7):5-6,8.

Duszak R. Up to code: RCCB's new certification exam recognizes deserving radiology coders. ACR Bulletin. January 2003;59(1):5-6,16