DIAGNOSTIC RADIOLOGY

The most standard radiographic procedures are contained in the Diagnostic Radiology subsection (70010-76499) of the Radiology section. This subsection describes diagnostic imaging, including plain x-ray films, the use of computed axial tomography (CAT or CT) scanning, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and angiography. CT scanning uses an x-ray beam that rotates around the patient, as illustrated in the figures/images shown above, the detail that can be obtained with MRI and CT scans. Special computer software is used with CT scanners to produce three-dimensional images that enable the study of internal structures. Tomography, CT scanning, and MRI may include the use of injectable dyes (radiographic contrast) to aid in imaging, and the codes are divided on the basis of whether or not contrast was used.

For example, under the subheading Spine and Pelvis (72010-72295), the codes for CAT, MRI, and MRA are divided as follows:

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72192 Computerized tomography, pelvis; without contrast material

72195 Magnetic resonance (e.g., proton) imaging, pelvis; without contrast material(s)

72198 Magnetic resonance angiography, pelvis, with or without contrast material(s)

Note one of these codes is for CAT, one code for the MRI, and one code for the MRA. The codes are divided by CAT, MRI, and MRA throughout the Diagnostic Radiology subsection.

So you must read carefully to ensure that you report the correct type of imaging. Fig. 28-12 is an example of a magnetic resonance image of the brain.

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In angiography, dyes are injected into the vessels to add contrast that facilitates the visualization of vessels’ lumen size and condition. The lumen is the cavity or channel within the vessel.

Angiography is performed to view blood vessels after injecting them with

a radio-opaque dye that outlines the vessels on x-ray. Angiography is used

to identify abnormalities inside the vessels. Figure/image shows an angiogram

of the aortic arch and brachiocephalic vessels. The radiologist studies the

vessels using angiography to detect conditions such as malformations, strokes,

or myocardial infarctions.

There are some combination codes in the angiography codes; so you must carefully read the complete procedure descriptor and parenthetical information to assure correct coding.

Codes in the Diagnostic Radiology subsection are divided according to anatomic site, from the head down. Some of the codes indicate a specific number of views, such as a minimum of three views or a single view. You should pay special attention to the description in each code and understand clearly how many views are specified in the code.

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Heart Cardiac magnetic imaging differs from traditional magnetic resonance imaging (MRI) in its ability to provide a physiologic evaluation of cardiac function. Traditional MRI relies on static images to obtain clinical diagnoses based upon anatomic information. Improvement in spatial and temporal resolution has expanded the application from an anatomic test and includes physiologic evaluation of cardiac function. Flow and velocity assessment for valves and intracardiac shunts is performed in addition to a function and morphologic evaluation. Use 75559 with 75565 to report flow with pharmacologic wall motion stress evaluation without contrast. Use 75563 with 75565 to report flow with pharmacologic perfusion stress with contrast.

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Vascular Procedures Aorta and Arteries Selective vascular catheterizations should be coded to include introduction and all lesser order selective catheterizations used in the approach (eg, the description for a selective right middle cerebral artery catheterization includes the introduction and placement catheterization of the right common and internal carotid arteries).

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Additional second and/or third order arterial catheterizations within the same family of arteries supplied by a single first order artery should be expressed by 36218 or 36248. Additional first order or higher catheterizations in vascular families supplied by a first order vessel different from a previously selected and coded family should be separately coded using the conventions described above. The lower extremity endovascular revascularization codes describing services performed for occlusive disease (37220-37235) include catheterization (36200, 36140, 36245-36248) in the work described by the codes. Catheterization codes are not additionally reported for diagnostic lower extremity angiography when performed through the same access site as the therapy (37220-37235) performed in the same session. However, catheterization for the diagnostic lower extremity angiogram may be reported separately if a different arterial puncture site is necessary. For angiography performed in conjunction with therapeutic transcatheter radiological supervision and interpretation services, see the radiology Transcatheter Procedures guidelines.

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Diagnostic angiography (radiological supervision and interpretation) codes should NOT be used with interventional procedures for:

1. Contrast injections, angiography, roadmapping, and/or fluoroscopic guidance for the intervention,

2. Vessel measurement, and

3. Postangioplasty/stent/atherectomy angiography, as this work is captured in the radiological supervision and interpretation code(s).

In those therapeutic codes that include radiological supervision and interpretation, this work is captured in the therapeutic code. Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:

1. No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study,

OR

2. A prior study is available, but as documented in the medical record:

a. The patient’s condition with respect to the clinical indication has changed since the prior study, OR

b. There is inadequate visualization of the anatomy and/or pathology, OR

c. There is a clinical change during the procedure that requires new evaluation outside the target area of intervention.

Diagnostic angiography performed at a separate sessions from an interventional procedure is separately reported. If diagnostic angiography is necessary, is performed at the same session as the interventional procedure and meets the above criteria, modifier 59 must be appended to the diagnostic radiological supervision and interpretation code(s) to denote that diagnostic work has been done following these guidelines. Diagnostic angiography performed at the time of an interventional procedure is NOT separately reportable if it is specifically included in the interventional code descriptor.

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Transcatheter Procedures Therapeutic transcatheter radiological supervision and interpretation code(s) include the following services associated with that intervention:

1. Contrast injections, angiography/venography, roadmapping, and fluoroscopic guidance for the intervention,

2. Vessel measurement, and

3. Completion angiography/venography (except for those uses permitted by 75898).

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Unless specifically included in the code descriptor, diagnostic angiography/venography performed at the time of transcatheter therapeutic radiological and interpretation service(s) is separately reportable (eg, no prior catheter-based diagnostic angiography/venography study of the target vessel is available, prior diagnostic study is inadequate, patient’s condition with respect to the clinical indication has changed since the prior study or during the intervention). See 75600-75893.

Codes 75956 and 75957 include all angiography of the thoracic aorta and its branches for diagnostic imaging prior to deployment of the primary endovascular devices (including all routine components of modular devices), fluoroscopic guidance in the delivery of the endovascular components, and intraprocedural arterial angiography (eg, confirm position, detect endoleak, evaluate runoff).

Code 75958 includes the analogous services for placement of each proximal thoracic endovascular extension. Code 75959 includes the analogous services for placement of a distal thoracic endovascular extension(s) placed during a procedure after the primary repair.

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Diagnostic Ultrasound All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated. For those codes whose sole diagnostic goal is a biometric measure (ie, 76514, 76516, and 76519), permanently recorded images are not required. A final, written report should be issued for inclusion in the patient’s medical record. The prescription form for the intraocular lens satisfies the written report requirement for 76519. For those anatomic regions that have “complete” and “limited” ultrasound codes, note the elements that comprise a “complete” exam. The report should contain a description of these elements or the reason that an element could not be visualized (eg, obscured by bowel gas, surgically absent).

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f less than the required elements for a “complete” exam are reported (eg, limited number of organs or limited portion of region evaluated), the “limited” code for that anatomic region should be used once per patient exam session. A “limited” exam of an anatomic region should not be reported for the same exam session as a “complete” exam of that same region.

Evaluation of vascular structures using both color and spectral Doppler is separately reportable. To report, see Noninvasive Vascular Diagnostic Studies (93880-93990). However, color Doppler alone, when performed for anatomic structure identification in conjunction with a real-time ultrasound examination, is not reported separately.

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.

Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.

Definitions

A-mode implies a one-dimensional ultrasonic measurement procedure.

M-mode implies a one-dimensional ultrasonic measurement procedure with movement of the trace to record amplitude and velocity of moving echo producing structures.

B-scan implies a two-dimensional ultrasonic scanning procedure with a two-dimensional display.

Real-time scan implies a two-dimensional ultrasonic scanning procedure with display of both two-dimensional structure and motion with time. (To report diagnostic vascular ultrasound studies, see 93880-93990) (For focused ultrasound ablation treatment of uterine leiomyomata, see Category III codes 0071T, 0072T)

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Chest Code 76641 represents a complete ultrasound examination of the breast. Code 76641 consists of an ultrasound examination of all four quadrants of the breast and the retroareolar region. It also includes ultrasound examination of the axilla, if performed.

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Code 76642 consists of a focused ultrasound examination of the breast limited to the assessment of one or more, but not all of the elements listed in code 76641. It also includes ultrasound examination of the axilla, if performed. Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final written report, is not separately reportable.

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Abdomen and Retroperitoneal A complete ultrasound examination of the abdomen (76700) consists of real time scans of the liver, gall bladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated abdominal abnormality.

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Pelvis Obstetrical Codes 76801 and 76802 include determination of the number of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestation (younger than 14 weeks 0 days), survey of visible fetal and placental anatomic structure, qualitative assessment of amniotic fluid volume/gestational sac shape and examination of the maternal uterus and adnexa.

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Codes 76805 and 76810 include determination of number of fetuses and amniotic/chorionic sacs, measurements appropriate for gestational age (older than or equal to 14 weeks 0 days), survey of intracranial/spinal/abdominal anatomy, 4 chambered heart, umbilical cord insertion site, placenta location and amniotic fluid assessment and, when visible, examination of maternal adnexa.

Codes 76811 and 76812 include all elements of codes 76805 and 76810 plus detailed anatomic evaluation of the fetal brain/ventricles, face, heart/outflow tracts and chest anatomy, abdominal organ specific anatomy, number/length/architecture of limbs and detailed evaluation of the umbilical cord and placenta and other fetal anatomy as clinically indicated.

Report should document the results of the evaluation of each element described above or the reason for non-visualization.

Code 76815 represents a focused “quick look” exam limited to the assessment of one or more of the elements listed in code 76815.

Code 76816 describes an examination designed to reassess fetal size and interval growth or reevaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound, and should be coded once for each fetus requiring reevaluation using modifier 59 for each fetus after the first.

Code 76817 describes a transvaginal obstetric ultrasound performed separately or in addition to one of the transabdominal examinations described above. For transvaginal examinations performed for non-obstetrical purposes, use code 76830.

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Nonobstetrical Code 76856 includes the complete evaluation of the female pelvic anatomy. Elements of this examination include a description and measurements of the uterus and adnexal structures, measurement of the endometrium, measurement of the bladder (when applicable), and a description of any pelvic pathology (eg, ovarian cysts, uterine leiomyomata, free pelvic fluid).

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Code 76856 is also applicable to a complete evaluation of the male pelvis. Elements of the examination include evaluation and measurement (when applicable) of the urinary bladder, evaluation of the prostate and seminal vesicles to the extent that they are visualized transabdominally, and any pelvic pathology (eg, bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess).

Code 76857 represents a focused examination limited to the assessment of one or more elements listed in code 76856 and/or the reevaluation of one or more pelvic abnormalities previously demonstrated on ultrasound.

Code 76857, rather than 76770, should be utilized if the urinary bladder alone (ie, not including the kidneys) is imaged, whereas code 51798 should be utilized if a bladder volume or post-void residual measurement is obtained without imaging the bladder. Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.

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Extremities Code 76881 represents a complete evaluation of a specific joint in an extremity.

Code 76881 requires ultrasound examination of all of the following joint elements: joint space (eg, effusion), periarticular soft-tissue structures that surround the joint (ie, muscles, tendons, other soft tissue structures), and any identifiable abnormality. In some circumstances, additional evaluations such as dynamic imaging or stress maneuvers may be performed as part of the complete evaluation.

Code 76881 also requires permanently recorded images and a written report containing a description of each of the required elements or reason that an element(s) could not be visualized (eg, absent secondary to surgery or trauma). When fewer than all of the required elements for a “complete” exam (76881) are performed, report the “limited” code (76882). Code 76882 represents a limited evaluation of a joint or an evaluation of a structure(s) in an extremity other than a joint (eg, soft-tissue mass, fluid collection, or nerve[s]).

Limited evaluation of a joint includes assessment of a specific anatomic structure(s) (eg, joint space only [effusion] or tendon, muscle, and/or other soft-tissue structure[s] that surround the joint) that does not assess all of the required elements included in 76881.

Code 76882 also requires permanently recorded images and a written report containing a description of each of the elements evaluated.

For spectral and color Doppler evaluation of the extremities, use 93925, 93926, 93930, 93931, 93970, or 93971 as appropriate.

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BREAST, MAMMOGRAPHY

Mammography (77051-77059) is the use of diagnostic radiology to detect breast tumors or other abnormal breast conditions, such as these codes used to report mammography services:

77055 Mammography; unilateral

77056 bilateral

77057 Screening mammography, bilateral (2-view film study of each breast)

Codes 77055 and 77056 report mammography performed to detect a suspected tumor.

For example, a patient who upon examination has demonstrated an abnormality in a breast would appropriately have the service reported with 77055. If, however, a patient has presented for the usual screening mammography, report the service with 77057. Note that the description for the usual screening mammography indicates “bilateral,” because screening mammography is performed on both breasts.

When new codes are published, their submission requires special attention. Under Radiology Guidelines, if a service is rarely provided, unusual, variable, or new, when submitting for reimbursement of the service a special report may be necessary. The report would include the complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic/therapeutic procedures, concurrent problems, and follow-up care.