October 31, 2011

ACR Radiology Coding Source™ for September-October 2011

2012 CPT® Code Update

[The Health Insurance Portability and Accountability Act transaction and code set rules require the use of the medical code set that is valid at the time a service is provided. All billing systems should be updated and the new 2012 codes available for use as of January 1, 2012. There is no grace period to implement new code sets.]

Pertinent changes in the Current Procedural Terminology (CPT®) 2012 codebook that will affect radiology practices will be made and will require revision to computer systems and charge sheets. Most of the changes for 2012 are based on the CPT®/ Relative Value Scale Update Committee (RUC) Five-Year Review Identification Workgroup request to specialty societies to move forward with code changes to address high frequency code pairs (code pairs reported together greater than 75 percent of the time), Harvard-valued codes with utilization greater than 100,000, substantially increased utilization, and site of service anomalies.

Diagnostic Radiology

[New] Computed Tomographic Angiography, Abdomen and Pelvis

74174     Computed tomographic angiography, abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing

Similar to the RUC request to create combined computed tomography (CT) abdomen and pelvis codes, the ACR and other radiology specialty societies were asked to create a combined code to describe computed tomographic angiography (CTA) of the abdomen and pelvis performed during the same session, as these codes are reported together greater than 75 percent of the time. Therefore, one new code (74174) was created to describe a combined CTA of the abdomen and pelvis. The stand-alone CTA abdomen code (74175) and CTA pelvis code (72191) will remain, as there are times a CTA abdomen or a CTA pelvis will be performed as a stand-alone procedure. 

The combined CTA abdomen and pelvis study code should not be reported in conjunction with the other CTA abdomen, pelvis, lower extremity, aorto-iliofemoral runoff or 3-D codes (72191, 73706, 74175, 75635, 76376, 76377). 

The CTA aorto-iliofemoral runoff code, 75635, includes CTA of the abdomen and pelvis; therefore, it is not appropriate to report 75635 in conjunction with the combined CTA abdomen and pelvis code. 

Deletion of Bone Density Codes

77079     Computed tomography bone mineral density study of the appendicular skeleton (eg, radius, wrist, heel) 
77083     Radiographic absorptiometry (eg, photodensitometry, radiogrammetry, 1 or more sites)

Code 77079, Computed tomography bone mineral density study of the appendicular skeleton (eg, radius, wrist, heel) and code 77083, Radiographic absorptiometry (eg, photodensitometry, radiogrammetry, 1 or more sites) will be deleted in 2012, as these procedures are obsolete and have been replaced by newer technology. 

Codes 77080 (axial), 77081 (appendicular) and 77082 (vertebral fracture assessment) remain and are available to describe dual-energy X-ray absorptiometry bone density studies of one or more sites. 

Code Revisions 

Lumbosacral Spine Codes

72114     Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views 
72120     Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views

Currently, there is confusion as to what constitutes a complete (72114) vs minimum 4-view (72110) vs bending views only (72120) study of the lumbosacral spine. Therefore, editorial changes were made to codes 72114 and 72120 to clearly differentiate when these codes should be reported. Bending views are included in a minimum six-view study of the lumbosacral area (72114) and not reported separately. Bending views only are reported with code 72120. Bending views performed in conjunction with any other type of views are reported with the appropriate code, i.e., 72100 (2 or 3 views) or 72110 (minimum of 4 views). 

Orthopantogram Code

70355     Orthopantogram (eg, panoramic x-ray)

Editorial revision was made to 70355, Orthopantogram, to list a panoramic x-ray as an example of this type of study. It is believed that code 76101, Radiological examination, complex motion…) is being used inappropriately by dentists and oral surgeons to describe a Panorex study. Therefore, a cross-reference also was added following code 76101 directing the coder to use 70355 to describe a panoramic x-ray study. 

Parentheticals Revisions 

Vertebroplasty Codes

22520-22522 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; …

The percutaneous vertebroplasty code descriptor has been updated to specify that the procedure includes a bone biopsy when performed; therefore, a bone biopsy code is not reported separately. The descriptor is similar to the code descriptor for the kyphoplasty codes, which already states bone biopsy included when performed. The cross-references following the vertebroplasty codes have been updated to denote that the bone biopsy and fracture reduction codes should not be reported in conjunction with the vertebroplasty codes.

(Do not report 22520-22522 in conjunction with 20225, 22310-22315, 22325, 22327 when performed at the same level as 22520-22522) 
(Do not report 22523-22525 in conjunction with 20225, 22310-22315, 22325, 22327 when performed at the same level as 22523-22525)

Ultrasound

Deletion of Non-invasive Physiologic Study of Extracranial Arteries

93875, Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis)

Code 93875, Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis), and 93880, Duplex scan of extracranial arteries; complete bilateral study, were identified as being reported together greater than 75 percent of the time. Because Doppler ultrasound is a component of 93880 and the other examples of noninvasive physiologic studies of extracranial arteries, namely periorbital flow direction with arterial compression and ocular pneumoplethysmography, are services that may no longer be performed, code 93875 will be deleted. The noninvasive physiologic testing was abandoned by the vast majority of physicians with the arrival of duplex ultrasonography. Most practitioners and societies believe this form of evaluation has been retired. 

Echocardiography 

The echocardiography introductory notes prior to the transthoracic echocardiography 933XX series section have been updated to describe when to report 93350 and 93351.

 … When only the professional components of a complete stress test and a stress echocardiogram are provided (eg, in a facility setting) by the same physician, use 93351 with modifier 26. When all professional services of a stress test are not performed by the same physician performing the stress echocardiogram, use 93350 in conjunction with the appropriate codes (93016-93018) for the components of the cardiovascular stress test that are provided.

Interventional Radiology

[New] Renal Angiography Catheter Placement Codes

ʘ 36251     Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiologic supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

ʘ36252     bilateral

ʘ36253 Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiologic supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

ʘ36254     bilateral

[Deleted] Renal Angiography Radiological Supervision and Interpretation Codes 

75722     Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation 
75724     Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation

Angiography codes 36215, 36216, 36245, 75650, 75671, 75680, 75722, and 75724, which were originally established in order to foster appropriate coding of procedures that vary from single-vessel studies to multivessel bilateral studies, were identified as code pairs performed together greater than 75 percent of the time. 

The specialty societies recommended that diagnostic renal arteriography be placed in a separate family of codes and considered separately from the cervicocranial codes, as the cervicocranial codes have a different anatomic focus. The set of codes describing unilateral renal angiography (75722 and 36245) and those codes describing bilateral renal angiography (75724 and 36245) will be replaced by four new codes differentiated by selective (first order vessel) vs superselective (second order or higher) and unilateral vs bilateral studies. The renal angiography radiological supervision and interpretation codes 75722 and 75724 will be deleted. 

[New] Intravascular Vena Cava Filter Codes

37191     Insertion of intravascular vena cava filter, endovascular approach inclusive of vascular access, vessel selection, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy) 
37192
     Repositioning of intravascular vena cava filter, endovascular approach inclusive of vascular access, vessel selection, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy) 
37193     Retrieval (removal) of intravascular vena cava filter, endovascular approach inclusive of vascular access, vessel selection, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy)

[Deleted] Inferior Vena Cava Filter Codes

37620     Interruption, partial or complete, of inferior vena cava by suture, ligation, placation, clip extravascular 
75940     Percutaneous placement of IVC filter, radiological supervision and interpretation

The inferior vena cava filter placement codes 37620, Interruption, partial or complete, of inferior vena cava by suture, ligation, placation, clip extravascular, and 75940, Percutaneous placement of IVC filter, radiological supervision and interpretation, will be deleted and replaced by three new codes that combine the procedure and imaging, and are differentiated by insertion, repositioning and retrieval (removal) of an intravascular vena cava filter. 

A separate code, 37619, Ligation of inferior vena cava, was created to describe an open surgical interruption of the inferior vena cava through a laparotomy or retroperitoneal exposure. 

[New] Abdominal Paracentesis Codes

49082     Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance 
49083     with imaging guidance 
49084     Peritoneal lavage, including imaging guidance, when performed

[Deleted] Peritoneocentesis, Abdominal Paracentesis, or Peritoneal Lavage Codes

49080     Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial 
49081         subsequent

The Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic) codes, 49080 (initial) and 49081 (subsequent), were identified by the CPT/RUC Identification Workgroup as codes for which the dominant providers have changed from when these codes were originally surveyed. Therefore, the specialty societies requested deletion of codes 49080 and 49081 and requested the creation of three new codes to describe abdominal paracentesis without imaging guidance (49082), abdominal paracentesis with imaging guidance (49083), and peritoneal lavage (49084). 

[New] Neurolysis Codes

●64633     Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT)); cervical or thoracic, single facet joint 
●+64634  cervical or thoracic, each additional facet joint 

●64635     Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 

●+64636     lumbar or sacral, each additional facet joint

[Deleted] Neurolysis Codes

   64622     Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level 
+64623     lumbar or sacral, each additional level 
  64626     cervical or thoracic, single level 
+64627    cervical or thoracic, each additional level

Neurolysis codes 64622-64627 were identified as high volume growth and/or on the Centers for Medicare & Medicaid Services fastest growing screens. These codes will be deleted and replaced by four new codes. Codes 64633 (cervical or thoracic) and 64635 (lumbar or sacral) to describe the injection of one or more nerves of a single facet joint. Add-on codes 64634 (cervical or thoracic) and 64636 (lumbar or sacral) describe each additional level when multiple facet joints are injected. 

Imaging guidance (fluoroscopy, CT) is bundled into codes 64633-64636 and should not be reported separately. 

Codes 64633-64636 describe a unilateral procedure, therefore, when a bilateral procedure is performed, modifier 50 should be appended. 

The introductory guidelines were updated to clarify that diagnostic and therapeutic injections are not reported separately.

[Revised] Sacroiliac Joint Injection Code

27096     Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

[Deleted] Sacro-iliac Arthrography Code

73542     Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation

The sacro-iliac (SI) joint injection code 27096 is being used inappropriately by some to describe a minimal contrast injection confirmation of needle position in the joint when doing a therapeutic injection. Code 27096 should only be reported when imaging guidance is used. Therefore, code 27096 was revised to bundle sacro-iliac (SI) joint therapeutic injections with imaging in order to stop this inappropriate reporting. Because 27096 is to be used for imaging confirmation of intra-articular needle positioning, a cross-reference under code 27096 directs the coder to use code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) when imaging is not performed. 

The radiological supervision and interpretation code 73542 will be deleted. 

Introductory Guideline Changes 

Diagnostic Studies of Arteriovenous (AV) Shunts for Dialysis and Interventions for 
Arteriovenous Shunts Created for Dialysis (AV Grafts and AV Fistulae) Introductory Guidelines 

A multispecialty society proposal consisting of the ACR, Society of Interventional Radiology, Society of Vascular Surgery, and the Renal Physicians Association was submitted at the request of the CPT Editorial Panel’s Executive Committee to provide guidelines to address ambiguities and misunderstandings related to the appropriate reporting of arteriovenous dialysis access coding. 

Detailed guidelines provide definitions of AV dialysis shunts, ultrasound guidance use, evaluation of the peri-anastomotic portion, arterial inflow to AV access, and interventions for AV shunts. Please review these detailed guidelines in the AMA’s CPT 2012 code book.

Nuclear Medicine

A number of nuclear medicine codes were identified in the RUC Five-Year Review Identification Workgroup screen of Harvard-valued codes with utilization greater than 100,000. The ACR and SNM recommended a comprehensive review of the entire family of lung ventilation and perfusion codes and hepatobiliary codes in an effort to simplify and reflect current imaging practice.

[New] Lung Ventilation and Perfusion

 
78579     Pulmonary ventilation imaging (eg, aerosol or gas) 
78582     Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging 
78597     Quantitative differential pulmonary perfusion, including imaging when performed 
78598     Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed

[Revised] Pulmonary Perfusion

78580     Pulmonary perfusion; imaging (eg, particulate)

[Deleted] 78584-78596

78584     Pulmonary perfusion imaging, particulate, with ventilation; single breath 
78585     rebreathing and washout, with or without single breast 
78586     Pulmonary ventilation imaging, aerosol; single projection 
78587     multiple projections (eg, anterior, posterior, lateral views) 
78588     Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, 1 or multiple projections 
78591     Pulmonary ventilation imaging, gaseous, single breath, single projection 
78593     Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection 
78594     multiple projections (eg, anterior, posterior, lateral views) 
78596     Pulmonary quantitative differential function (ventilation/perfusion) study

 
Lung ventilation and perfusion codes 78584-78596 will be deleted and replaced by four new codes (78579, 78582, 78597 and 78598). In addition, code 78580 will be revised to designate particulate as an example. Because there is little work or cost difference between a gas and aerosol technique, the ACR and SNM recommended consolidation of these ventilation study codes, before they went back to the RUC for re-surveying. The codes available for use in 2012 will describe a perfusion only study (78580), a ventilation only study (78579) and a combined ventilation and perfusion study (78582). Two new quantitative differential function study codes, including imaging when performed, will be available to differentiate between a perfusion only study (78597) and a perfusion and ventilation study(78598).

[New] Hepatobiliary

78226     Hepatobiliary system imaging, including gallbladder when present; 
78227     Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed

[Deleted] Liver and Hepatobiliary Codes

78220     Liver function study with hepatobiliary agents, with serial images 
78223     Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function

The hepatobiliary code 78223 was caught in the Harvard-valued codes with utilization greater than 100,000. To address questions regarding the proper use of the hepatobiliary codes and prior to going to the RUC to be re-surveyed, the ACR and SNM recommended that the hepatobiliary codes be revised. Codes 78220, Liver function study…, and 78223, Hepatobiliary ductal system imaging…, will be deleted and replaced with codes 78226 (Hepatobiliary system imaging, including gallbladder when present) and 78227 (…with pharmacologic intervention including quantitative measurement(s), when performed),respectively. These new codes accurately describe hepatobiliary imaging that is currently performed and account for the major differences in the physician and technical work required when performing a hepatobiliary study with pharmacologic intervention. 

Revised Injection Procedure Code

38792     Injection procedure; radioactive tracer, for identification of sentinel node

Code 38792 was revised to clarify that this code is used to describe a radioactive tracer injection, therefore, the descriptor now specifies Injection procedure; radioactive tracer, for identification of sentinel node.

Radiation Oncology

[New] Intra-operative Radiation Treatment Delivery and Management Codes

77424     Intra-operative radiation treatment delivery, x-ray, single treatment session 
77425     Intra-operative radiation treatment delivery, electrons, single treatment session 
77469     Intra-operative radiation treatment management

Revised] Special Treatment Procedure Code 

    77470, Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary irradiation) 

New codes were created to describe intra-operative radiation treatment (IORT) delivery in a single treatment session differentiated by the type of radiation source, i.e., x-ray (77424) vs electrons (77425), as the times for treatment delivery, staffing requirements, and machine capital requirements are vastly different for IORT treatments compared to conventional treatment described by existing codes. 

In addition, code 77469 was created to describe IORT management, as patient management for a single fraction in the clinic does not include the significant work that is required to set up and manage treatment in an exposed surgical field. 

The radiation treatment management introductory guidelines, prior to the treatment management code listing, notes that the IORT management code 77469 represents only the intraoperative session management and does not include medical evaluation and management outside of the session. 

It is not appropriate to report the RO treatment delivery codes 77280-77290 and 77401-77412 in conjunction with the IORT delivery codes 77424-77425, or to report the RO treatment management code 77431 in conjunction with the IORT management code 77469, as that would represent unbundling. 

With the creation of new codes to describe IORT delivery and management, code 77470, Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) will be revised and the intraoperative cone irradiation example deleted from the descriptor.

Other

A number of existing CPT codes were marked with the bull’s eye symbol to designate that moderate (conscious) sedation is included in the procedure and should not be reported separately. They include CPT codes:

ʘ 36200     Introduction of catheter, aorta

ʘ 36245     Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family

ʘ 36246     Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family

ʘ 36247     Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family

ʘ 36248     Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)

ʘ 37203     Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter)

Category II Codes

The descriptors for Category II codes 3111F and 3112F, which describe the Computed Tomography and Magnetic Resonance Imaging Reports measure, have been editorially revised to denote these codes apply to intracranial hemorrhage.

3111F CT or MRI of the brain performed in the hospital within 24 hours of arrival OR performed in a outpatient imaging center, to confirm initial diagnosis of stroke, TIA or intracranial hemorrhage(STR)

3112F CT or MRI of the brain greater than 24 hours after arrival to the hospital OR performed in a outpatient imaging center for purpose other than confirmation of initial diagnosis of stroke, TIA or intracranial hemorrhage(STR)

Category III Code Changes

0080T Endovascular repair using prosthesis of abdominal aortic aneurysm, pseudoaneurysm or dissection, abdominal aorta involving visceral vessels (superior mesenteric, celiac and/or renal), using fenestrated modular bifurcated prosthesis (2 docking limbsartery[s]), radiological supervision and interpretation

For a complete listing of new Category III codes approved but not included in the CPT 2012 code book, go to the AMA Web site at www.ama-assn.org/ama1/pub/upload/mm/362/cptcat3codes.pdf.

Category III codes are used primarily for tracking new procedures and are not referred to the AMA Relative Value Scale Update Committee for valuation. However, they are carrier priced if the service is covered.

Updates are posted biannually (January and July) and are effective six months after posting. This delay provides time for providers/payers to update systems. These codes are maintained until they meet Category I code requirements or they are archived after five years unless a further need is demonstrated to maintain the Category III code status. Click here for more detailed information on CPT® Category I, II and III codes.

Please refer to the CPT 2012 codebook for a complete listing of new and revised CPT® codes and guidelines, and the Fall 2011 Clinical Examples in Radiology Bulletin for a crosswalk to the new 2012 radiology codes, as well as the Winter 2012 and future issues for detailed discussions on the reporting of these codes.

1AMA's CPT Changes 2011: An Insider's View. CPT 2012, p.373.

2AMA CPT Changes 2012: An Insider’s View.