Presented by:

Kathleen G. Bailey, CPA, MBA, CPC, CPCO, CPMA, CPC-I, CCS-PAAPC Certified ICD-10-CM & PMCC Instructor

Practice Management Solutions Tampa, FL

Kathleen holds BS in Accounting and MBA degrees from Florida State University and is a CPA licensed in both FL & GA. Because healthcare is an ever changing environment she is a member of several professional organizations including: AAPC where she earned CPC, CPCO, CPMA, CPC-I, and ICD-10-CM Instructorcertifications; AHIMA, where she earned CCS-P certification; MGMA; RBMA; HFMA and other local, state and national healthcare organizations.

She is a frequent speaker for nationally recognized professional organizations and specializes in coding education (including ICD-10-CM), accounts receivable management, managed care negotiations, and physician relationships.

Understanding from experience that practices can benefit greatly from business expertise, Kathleen founded Practice Management Solutions in 2006. Prior to this her experience included working as a practice administrator for anesthesia, radiology, general surgery, OB/GYN, primary care and internal medicine practices for over 25 years. In addition, she has worked in the education arena for over nine years serving as Dean of Online Programs for a college in Tampa Florida and as an adjunct instructor forseveral online universities in their Health Information and Healthcare Management programs.

She is very familiar with the difficulties facing today's healthcare organizations. Her experience offers clients ideas and solutions to improve their lives and the lives of their patients.

Welcome! It is my intent to bring you only the best coding, billing and practice management information. I hope that you will find this presentation helpful as well as educational.

The purpose of this material is to accompany the presentation. The materials are only supplemental and are not intended as a substitute for authoritative information. The were prepared by the presenter, who is responsible for their content. There is no guarantee that the use of this information will prevent differences of opinion with providers or carriers in reimbursement disputes. Neither the presenter nor any third party sponsor provides any warranties, express or implied, regarding the content of this material due to constantly changing regulations, laws, policies and procedures.

This material is only intended to be used as a teaching tool to accompany the oral presentation.

• History of Radiology

• Uses for Radiation and Other Imaging Methodologies:

• Modalities included in “Diagnostic Imaging”

• General Diagnostic

• Computed Tomography (CT) / CTA

• Magnetic Resonance Imaging (MRI) / MRA

• Ultrasound

• Women’s Imaging

• Radiation Therapy services

• Nuclear Medicine, including PET, PET/CT PET/MR

• Interventional Radiology Coding

• Radiation Therapy Coding

• Questions …

• Radiology Specific Terminology

• Resources …

• Radiology is a service offered by many

healthcare organizations

• Understanding the different modalities as

well as compliance with the guidelines for

coding of radiology services can help your

organization assure imaging services

receive proper reimbursement

• Discovered by Wilhelm Conrad Roentgen on November 8th of 1895

• He announced discovery of a “new kind of ray” which could penetrate living human flesh

• It changed the face of medical practice

• For his work, Roentgen received the Nobel Prize in Physics in 1901

• First known x-ray

image is of

Roentgen wife’s

hand

The first radiograph was an image of Wilhelm Röntgen’s wife’s hand.

• Today there are over 36,000 members of the

American College of Radiology (ACR) in the

US and more than 53,000 international

members of the Radiological Society of North

America (RSNA)

Scientific discipline

of medical imaging

Which uses ionizing

radiation, magnetic resonance, ultrasound,

radionuclides, nuclear and other modalities to

diagnose and treat patients

• Physician who specializes in diagnosing and treating disease

& injury through the use of medical imaging modalities

• Training includes medical school, passing licensing

examinations, and completion of internship/residency of 3 – 5

years that includes training in:• Radiation safety/protection

• Radiation effects on the human body

• Appropriate performance and interpretation of radiologic and

medical imaging examinations

• Many radiologists also complete a fellowship which includes

several years of specialized training in a particular

subspecialty:• Breast Imaging

• Gastrointestinal Radiology

• Pediatric Radiology

• Neuroradiology

• Nuclear Medicine

• Cardiovascular/Interventional Radiology

• Neuro-Interventional Radiology

• Radiation Therapy

• Since 1987 the ACR has accredited

more than 35,000 facilities

• Accreditation programs in CT, MRI,

breast MRI, nuclear medicine and

PET, mandated under the

Medicare Improvements for

Patients and Providers Act

(MIPPA)

• Also for modalities mandated under

the Mammography Quality

Standards Act (MQSA)

• Breast MRI

• Breast Ultrasound

• Computed Tomography

• Mammography Resources

• MRI

• Nuclear Medicine & PET

• Radiation Oncology

• Stereotactic Breast Biopsy

• Ultrasound

http://www.acr.org/Quality-Safety/Accreditation

15

• Evidence-based guidelines to

assist in making the most

appropriate imaging or

treatment decision for a

specific clinical condition

• Enhance quality of care and

contribute to efficacious use

of radiology

16

• Help advance the science

of radiology and improve

the quality of service for

patients

• Promote safe and effective

use of diagnostic and

therapeutic radiology

• Anteroposterior (AP): front to back

• Axial: around the axis

• Cone: focused or spot view

• Decubitus: lying down

• Distal: away from the center of the body

• Dorsal: back of the body

• Erect: standing up

• Extension: straightening

• Flexion: bending

• Frontal: anterior/ventral (front)

• Inferior: below, or at the bottom

• Lateral: side view

• Medial: in the middle

• Oblique: slanting, neither frontal or lateral

• Posteroanterior (PA): back to front

• Prone: face down or palm down

• Proximal: near the center of the body or point of attachment to the body

• Recumbent: lying down

• Superior: above, or at the top

• Supine: face up or palm up

• Ventral: front of the body

• Position: Way in which patient is placed

• Projection: Path the x-ray beam travels

As with other specialties, it is important to code the definitive

diagnosis

Use signs & symptoms if no definitive diagnosis

Diagnostic tests– Code sign or symptom that prompted the test

– While it is appropriate for the referring physician to include “Rule

Out” criteria in the order for an exam, do NOT code questionable,

rule out, or probably diagnoses for billing purposes

Routine:– Z01.89 Radiological examination, NEC

Important to coordinate laterality with CPT &/or modifier(s) (i.e.:

LT, RT, 50)

Procedure coding for Radiology is divided into subsections:o Diagnostic Radiology

- Aorta & Arterieso Diagnostic Ultrasoundo Radiologic Guidanceo Breast, including Mammographyo Bone/Joint Studieso Radiation Oncologyo Nuclear Medicine

However, codes for radiology services can also be located in other sections of the CPT

This presentation will emphasize compliance with codes in the Radiology section

• Make sure to read ALL Guidelines at the beginning of

the Radiology Section of your CPT manual (pages

highlighted in green)

• Separate procedure: integral to another procedure

unless carried out separately

• Unlisted Procedures:

• Category III code?

• Special Report

• When to use Supervision and Interpretation (S & I) codes from the Radiology section

• Administration of Contrast materials: the statement “with contrast” implies a contrast injection (Intravascular (IV), Intra-Articularly (IA), Intrathecally(IT))

• Oral and/or rectal contrast do NOT qualify for “with contrast” coding

• Written Reports

• Permanent record of the “images”

• Also pay close attention to Instructional Paragraphs

within the Radiology section

• Examples:

• Heart: 75557 – 75574

• Vascular Procedures: 75600 – 75635

• Aortography: 75658 – 75774

• Etc.

• Parenthetical Notes

• Example: 75809, shuntogram… indicates:

(For procedure, see 49427 or 61070)

Notes regarding new or revised text

• Professional Component: Physician portion of service, includes

• Supervision of technician and Interpretation of results, including written report

• Report with 26 modifier

• Technical Component:

• Technologist, rent/facility, equipment, film/PAC, supplies, etc.

• TC modifier

• Global Services: Both professional and technical portions of radiology service

• Facility where procedure was performed owns the equipment and employs the radiologist who interprets the exam

• No modifier

• Professional component:

• 71020-26 (Supervision and final report)

• Technical component:

• 71020-TC (Technician, supplies, equipment)

• Global procedure:

• 71020 (both professional & technical)

• Third-party payers typically reimburse approximately:

• 40% professional component

• 60% technical component

• Radiology codes are often divided based on the extent of the study

• Example: Extent of scan as follows

• Complete: Scans entire body structure

• Limited: Scans part of body, i.e., one organ

• Follow-up/repeat: Limited study of part of body that was scanned previously

• If fewer than total number of views specified in code provided:

• Modifier -52, Reduced Service

• Repeat procedures:

• Modifier -76, same radiologist (same day)

• Modifier -77, different radiologist

• Written report must document time performed, etc.

• Uses electromagnetic

energy in the form of x-rays

to create medical images

• This CPT subsection includes: “Plain Film” x-ray,

Computed Tomography (or CT), Computed Tomography

Angiography (or CTA), Magnetic Resonance Imaging (or

MRI), Magnetic Resonance Angiography (called MRA), and

Angiography and other Interventional services

• Codes are listed by anatomic location (head, abdomen,

etc.), then by modality plus whether or not contrast

material is utilized

• Many codes are based on number of views completed

• Used to:

• Diagnose diseases

• Monitor disease process, progression and/or remission

• Therapeutic procedures and guidance

• First CT system was invented by Godfrey Newbold Hounsfield in Hayes, England who conceived his idea in 1967, publicly announced in 1972

• Allan McLeod Cormack of Tufts University independently invented a similar system

• They shared the Nobel Prize in medicine in 1979

• Imaging of anatomical information from a cross-

sectional plane of the body, each image is

generated by a computer synthesis of x-ray data

• Hounsfield linked x-ray sensors to a computer and

worked out a mathematical technique called

algebraic reconstruction to assemble images from

the transmitted data

• Sometimes referred to as CAT scan

(computerized axial tomography)

• The Protecting Access to Medicare Act (PAMA) included requirements that

health care providers comply with the National Electrical Manufacturers

Association (NEMA) XR-29 Standard Attributes on CT Equipment Related

to Dose Optimization and Management, also known as MITA Smart Dose

• Effective Jan. 1, 2017, CT equipment that does not comply with all four

attributes of the NEMA XR-29 Standard is subject to a 15% per scan

reduction in reimbursement for the technical component (TC)

• Going forward, the ACR will request copies of Certificates of NEMA XR-29

Compliance for each CT unit as part of the ACR’s routine accreditation

application and renewal process

• As previously mentioned, it is very important to correctly code for

Contrast Administration (i.e.: IV, IT, IA only… oral and rectal do NOT

count)

• Codes are shown for an exam “without contrast material(s)”

• Followed by indented codes for an exam “with contrast

material(s)”

• And… an exam “without contrast material(s) followed by contrast

material(s)”

• Note: the type & amount of contrast should be clearly stated in the

radiology report

• February 5, 2015 CMS released a final NCD which found evidence sufficient to permit high risk patients to receive annual LDCT scans without cost sharing.

• High risk patients are individuals between 55 and 77 who smoked at least one pack of cigarettes every day for 30 years or ceased tobacco use within the last 15 years.

• The NCD also outlines reasonable guidelines, as well as minimum quality standards & requirements for both imaging centers and radiologists to provide or interpret LDCT scans.

For More Information

• American College of Radiology (ACR):http://https://www.acr.org/Quality-Safety/Resources/Lung-Imaging-Resources

• A method of examining blood vessels

• MRI uses a powerful

magnetic field, radio frequency

pulses and a computer to

produce detailed images of

organs, soft tissues, bone and

other internal body structures

• MRI does not use ionizing

radiation (x-rays)

• The strength of an MR is calibrated in “Tesla Units”

• Low-Field MRI= Under .2 Tesla

• Mid-Field MRI= .2 to 0.6 Tesla

• High-Field MRI= 1.0 Tesla and above

Open MRI Extremity MRI

Stan-Up MR

Remember: codes are divided depending on whether or not intravascular (IV), intra-articular (IA) or intrathecal (IT) contrast material is used

• Seeing Both Sides: A CT scanner’s X-rays [left side] provide good structural detail; MRI images [right] are good for seeing functional flaws

• In MRA a powerful

magnetic field, radio

frequency waves and

a computer produce

detailed images of the

major arteries within

the body

• Clinical subspecialty usingfluoroscopy, CT, and ultrasound to guide percutaneous (through the skin) procedures such as biopsies, draining fluids, inserting catheters, or dilating or stenting narrowed ducts or vessels

• May require the use of catheter(s) and the injection of x-ray contrast material to visualize anatomy

• Used to view vessel obstructions and diagnose vascular conditions

• Examples:

• Malformations

• Strokes

• Myocardial infarction Angiography of aortic arch &

brachio-cephalic vessels

• There are many combination codes in interventional

cardiology/radiology, so it is important to read the

guidelines, complete procedure descriptions and

parenthetical notations to assure correct coding

• Appendix L in the CPT manual can also be helpful in

identifying the appropriate vascular family for

interventional cases

• Coding for Moderate (Conscious) Sedation is changed for 2017

• Prior codes (99143-99150) have been deleted

• New codes (99151 – 99157) based on:

• Age of patient

• Who provides the service

• Length of procedure

• Code(s) for initial 15 minutes

• Add-on code(s) for each additional 15 minutes

• Issues reported with denials due to CCI edits

• Society of Interventional Radiology:https://www.sirweb.org/

• Uses high-frequency

sound energy to create images

• Does not use ionizing radiation

• Has wide variety of medical applications

• CPT subheadings primarily based on anatomy

• Example:

• Head and Neck

• Chest

• Pelvis

• Important to read instructions and parenthetical notes for correct code assignment

• Must have permanent record of “images”

• A-mode or A-scan technology— one-dimensional

• Used to map structure outline, displays one-dimensional image

• M-mode: one-dimensional measurement with movement to allow amplitude and velocity of moving echo-producing structures

• Used to display movement of structure, displays one-dimensional image

• B-scan technology: two-dimensional, Real-time scan

• A & B scan may be performed together (medical necessity must be documented)

• Technique used to display movement of tissue and organs

• Real Time Scan - Displays two-dimensional image

• Used to display both structure and motion of organs and tissue

• ACR Ultrasound Coding User's Guide:

https://shop.acr.org/Default.aspx?TabID=55&ProductId=1484637171

• Radiologic Guidance:• Ultrasound (Note: listed in Ultrasound sub-section 76930-76965)

• Fluoroscopic

• Computed Tomography (CT) • Magnetic Resonance guidance (MR)

• Uses low-energy X-ray to examine the

human breast

• A diagnostic and a screening tool

• Goal of mammography is the early

detection of breast cancer, typically

through detection of characteristic masses

and/or microcalcifications

• There are three new codes to describe mammography services

for 2017

• 77065 Diagnostic mammography, including computer-aided

detection (CAD) when performed; unilateral

• 77066 Diagnostic mammography, including CAD when performed;

bilateral

• 77067 Screening mammography, bilateral (2-view study of each

breast), including CAD when performed

• Unlike prior codes (77051, 77052, 77055, 77056, and 77057), the

new codes include computer-assisted detection (CAD)

• However, CMS does not intend to recognize the new CPT codes until 2018

• Medicare claims for mammo in 2017 must continue to use G codes:

• G0202 Screening mammography, bilateral (2-view study of each breast), including computer- aided detection (CAD) when performed

• G0204 Diagnostic mammography, including CAD when performed; bilateral

• G0206 Diagnostic mammography, including CAD when performed; unilateral

• Also called 3-D breast imaging,

a mammography system where

the x-ray tube moves in an arc

over the breast creating a

images of thin slices through

the breast that allow improved

detection of cancer and fewer

patients recalled for additional

imaging

• Breast tomosynthesis is described using the following add-on codes:

• 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)

• G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206)

• When furnished, report one of G0202, G0204, or G0206 and one of G0279 or 77063

• Appropriate, accompanying 2D image(s) may either be acquired or synthesized

• CMS FAQ: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-Mammography-Services-Coding-Direct-Digital-Imaging.pdf

• Bone/Joint Studies (77071-77086)• Bone density scanning, also called dual-energy x-ray

absorptiometry (DXA) or bone densitometry, is an enhanced form of x-ray technology that is used to measure bone loss

• Cancer physicians usually treat cancer with

radiation therapy, surgery or medications, including

chemotherapy, hormonal therapy and/or biologic

therapy, either alone or in combination

• If cancer can be treated with radiation, patients are

referred to a Radiation Oncologist — a physician who

specializes in treating patients with radiation therapy

• Radiation oncologists work with primary care physicians and other cancer specialists, such as surgical and medical oncologists, to oversee care

• He/she discusses the details of the treatment with the patient, the role of radiation therapy in the overall treatment plan and what to expect

• Physicians have been treating patients with radiation therapy for over 100 years

• Approximately two-thirds of cancer patients are treated with some form of radiation

• In this subsection, special attention must be given to

reporting the professional and/or technical component

of procedures

• Codes include those that can be used in management

of the patient from the initial consultation throughout

the entire course of treatment

• The initial consultation can be reported with a code

from the E&M (Evaluation and Management) section,

i.e.: inpatient or outpatient

• Radiation Oncology:• Clinical Treatment Planning • Medical Radiation Physics, Dosimetry, Treatment Devices,

and Special Services• Stereotactic Radiation Treatment Delivery• Other Procedures• Radiation Treatment Delivery• Neutron Beam Treatment Delivery• Radiation Treatment Management• Proton Beam Treatment Delivery• Hyperthermia• Clinical Intracavitary Hyperthermia• Clinical Brachytherapy

• Treatment Planning is the radiation oncologist’s

description of how a patient should be treated

with radiation therapy

• The radiation oncology team attempts to

maximize radiation to the tumor while sparing

healthy tissue and organs

• A treatment plan is established for any patient requiring radiation therapy

• May include:

• Interpretation of special testing

• Tumor localization

• Determination of treatment volume

• Choice of treatment method

• Determination of number of treatment ports

• Selection of treatment devices

• Other necessary procedures

• Clinical Treatment Planning consists of

• Planning

• Simulation

• Blocks: Pieces of metal alloy that can be used to

shape the radiation beam from a linear accelerator

• Port Films: images made, during your course of

treatment, using the treatment beam itself to verify the

correct positioning of the treatment beams

• Immobilization Device: Device used to help a patient

remain in the same position during every treatment

• Planning Levels:

• Simple: One treatment area, one port or one set of

parallel ports

• Intermediate: Three or more ports, two separate

treatment areas, multiple blocking

• Complex: Complex blocking, custom shielding blocks,

tangential ports, special wedges, three or more

treatment areas, special beams

• Process of planning radiation therapy to allow the radiation to be delivered to the intended location

• Does not include administration of radiation

• Three levels of simulation:

• Simple: One treatment area with one port or pair of ports

• Intermediate: Three or more ports, two separate treatment areas, multiple blocking

• Complex: Tangential ports, three or more treatment areas, complex blocking

• Decision-making services of physicians

• Treatment types

• Dose calculation and placement (dosimetry)

• Development of treatment device

• Actual delivery of radiation treatment:• Stereotactic Radiation Treatment

• Neutron Beam

• Proton Beam Treatment

• Hyperthermia treatments, include: external

(superficial & deep), interstitial, and intracavitary

• Clinical Intracavitary Hyperthermia

• Clinical Brachytherapy

• Amount of radiation delivered

• Type of radiation treatment, etc.

• Number of:

• Areas treated: (single, two, three or more)

• Ports involved: (single, three or more, tangential)

• Blocks used: (none, multiple, custom)

• Professional (physician) portion of services, including:• Review port films

• Review dosimetry, dose delivery, treatment parameters

• Treatment set-up

• Patient examination for medical E/M

• Report in units of five fractions

• See Radiation Management & Treatment Table

• American Society for Radiation Oncology: https://www.astro.org/Coding.aspx

• Nuclear medicine codes report placement of radionuclides within the body and monitoring of emissions from the radioactive elements

• Used both for diagnosis and treatment

• Codes divided primarily on organ system

• Codes do NOT include radiopharmaceuticals used, supplies are billed in addition to the service provided

• Includes: • PET (Positive

Emission

Tomography)

• PET / CT:

• PET / MR:

• ACR Nuclear Medicine Coding User's Guide:https://shop.acr.org/Default.aspx?TabID=55&ProductId=1484637441

Society of Nuclear Medicine and Molecular Imaging http://www.snmmi.org/

• AAPC: www.AAPC.com

Certified Professional Coder (CPC)

Certified Outpatient Coder (COC)

Certified Inpatient Coder (CIC)

Certified Interventional Radiology Cardiovascular Coder (CIRCC)

• Radiology Certified Coder (RCC): www.RBBC.org

Radiology Coding Certification Board (RCCB)

Kathleen G. Bailey, CPA, MBA, CPC, CPCO, CPMA, CPC-I, CCS-P

AAPC Certified ICD-10-CM & PMCC Instructor

Cell Phone: (850) 544-0838

email: Kathleen_ Bailey@tampabay.rr.com

Healthcare Management Consultants, Advisors & Educators

• Bone Densitometry: also called dual-energy x-ray absorptiometry (DXA) or bone densitometry, is an enhanced form of x-ray technology that is used to measure bone loss. DXA is today's established standard for measuring bone mineral density (BMD).

• Computed Tomography: more commonly known as a CT or CAT scans, is a diagnostic medical test that, like traditional x-rays, produces multiple images of the inside of the body. Cross-sectional images generated during a CT can be reformatted in multiple planes, and generate 3D images. Like MRI, CPT codes for CT are found under the body area being scanned.

• Fluoroscopy: provides live images and allows study of the function as well as the structure of the organ. The name for the study of the function of the organ is Physiology. The name for the study of the structure of the organ is anatomy.

• Interventional Radiology: is a medical specialty that performs minimally invasive treatments using radiologic imaging for procedure guidance.

• Ionizing Radiation: is radiation of sufficient energy to dissociate atoms or molecules into electrically charged atoms or radicals in the irradiated material.

• Magnetic Resonance Imaging (MRI): a diagnostic radiologic modality, in which the nuclei of the hydrogen atoms in a patient are aligned in a strong, uniform magnetic field, absorb energy from tuned radio pulses, then emit radio signals. These signals are converted into images which appear as cross-sectional slices of the patient’s body.

• Mammography: Imaging examination of the breast by means of x-rays, used for screening and diagnosis of breast disease. Ultrasound and magnetic resonance may also be used to image the breast.

• Nuclear medicine technology: branch of radiology that involves the introduction of radioactive substances into the body for both diagnostic and therapeutic purposes.

• Radiation: energy transmitted by waves through space or through a medium.

• Radiation therapy: branch of radiology involved in the treatment of disease by means of x-rays or radioactive substances.

• Radiography: making of records (radiographs) of internal structures of the body by passing x-rays or gamma rays through the body to act on specially sensitized film or imaging plate or system.

• Radiologist: physician who specializes in the use of roentgen rays and other forms of radiation in the diagnosis and treatment of disease.

• Radiology: 1) The science of high energy radiation and of sources and the

chemical, physical, and biologic effects of radiation; the term usually refers to

diagnosis and treatment of disease. 2) Scientific discipline of medical imaging using

ionizing radiation, radionuclides, nuclear magnetic resonance, and ultrasound.

• Roentgen Ray: synonym for x-ray

• Ultrasound Imaging: also known as sonography, is a method of obtaining images

from inside the human body through use of high frequency sound waves. Soundwave

echoes are recorded and displayed as real-time, visual images. No ionizing radiation

is involved in ultrasound imaging.

• X-Ray (radiograph): is a noninvasive medical test that helps physicians diagnose

and treat medical conditions. Involves exposing a part of the body to a small dose of

ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest

and most frequently used form of medical imaging.

“Introduction to Radiologic Sciences and Patient Care,” 5th Edition; Arlene Adler and Richard Carlton

American Academy of Professional Coders:

www.AAPC.com

“Step by Step Medical Coding,” 2016 Edition; Carol J. Buck, MS, CPC-I, CPC, CPC-H, CCS-P

American College of Radiology

http://www.acr.org

Radiological Society of North America

http://www.rsna.org

https://www.RadiologyInfo.org

Society of Interventional Radiology

http://www.sirweb.org/

American Medical Association

http://www.ama-assn.org/