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Imaging Radiological Procedures

Q.  What is the proper CPT® code for a post-voiding bladder residual ultrasound (PVR)?

A.   When performing a post-voiding residual urine ultrasound, use CPT® code 51798, Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging. However, the AUA Coding and Reimbursement Committee has established that no matter which type of ultrasound machine (imaging or non-imaging) is used to perform the diagnostic procedure, if the intent is to obtain a PVR, then use CPT® code 51798.

There are many commercial insurers who do not recognize that CPT® code 51798 has a XXX global and therefore no global period applies. This procedure should be treated as a radiological procedure and be reimbursed in addition to any surgical procedure or E&M service. If denials are made for this reason, append modifier -25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service, to the E&M service and appeal the denial. The AUA has developed appeal letters for assistance in asking the carrier to address the denial of the PVR when billed along with the E&M service. Contact the AUA's Coding Hotline at 866-746-4282 (option 3 ) or download the letter.

Q.   Is CPT® code 76000, Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy) inherent in CPT® code 50590, Lithotripsy, extracorporeal shock wave?

A.   Yes, fluoroscopy has been bundled into ESWL. This means for Medicare claims, modifier -59 Distinct procedural service must be appended to code 76000 to receive reimbursement. There must be medical necessity for the use of fluoroscopy apart from locating the stone for the lithotripsy.

Q.   My urologist performs retrograde pyelograms CPT® code 52005 in conjunction with many cysto/ureteroscopy procedures. Can I bill separately for the retrogrades?

A.   According to Medicare Correct Coding Initiative (CCI) edits, retrograde pyelograms are bundled into cystoscopy codes 52320 through 52355 and cannot be unbundled, unless the procedure is performed on separate ureters. If the retrograde is performed to complete the procedure, CCI considers the retrograde inherent to the endoscopy procedure performed. However, if the physician performed the supervision and interpretation of the retrograde, the urologist may bill the 74420 urography, retrograde, with or without KUB. If the physician does not own the equipment, a -26 modifier must be appended to the 74420. A separate paragraph must be dictated with findings. Remember this CPT® code is a radiology procedure so if the procedure was done in the hospital and the hospital bills for the service first the urologist will not get paid.

Q.   Is a separate report required for diagnostic testing (such as transrectal ultrasound, renal ultrasound, post-void residual)?

A.  Yes, all CPT® services (E&M, procedures and radiology) must be documented. The American Medical Association clarified this issue in the E&M Services Guidelines Section in the CPT® book. The language reads:

"The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E&M services. Physician performance of diagnostic test/studies for which specific CPT® codes are available may be reported separately, in addition to the appropriate E&M code. This physician interpretation of the results of diagnostic tests/studies with preparation of a separate, distinctly identifiable signed written report may also be reported separately, using the appropriate CPT® code with the modifier -26, Professional Component, appended."

However, many insurance companies, including Medicare, will not pay for both the radiologist's interpretation of a diagnostic study and for the physician who reads and interprets the results of a diagnostic test performed outside the physician's office. If the physician performs the procedure and interprets the result, coordinate billing on this with the hospital. The hospital should bill for the technical component (-TC) and the physician should bill for the professional component (-26).If the tests/studies are performed in the physician's office, bill the CPT® code for the actual test. No modifiers breaking out the technical and professional components are necessary. A separate written report is required for the patient's chart.

Q.   In 2016, CPT® revised its radiology guidelines for written reports. How does this impact my documentation for radiology services?

A.   The CPT® Editorial Panel convened a workgroup to review the phrase "written report" with recommendation of alternate language to reflect the common creation of electronically formatted reports. The workgroup reviewed the current guidelines relevant to "written report" and "supervision and interpretation," along with the guidelines for reporting ultrasound and revised the guidelines to reflect current practice.

The following revisions have been made in the introductory guidelines of the radiology section of the 2016 CPT® manual (edits in underlined italics below):

A written report (e.g., handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.

With regard to CPT® descriptors for radiography services, "images" refers to those acquired in either an analog (i.e., film) or digital (i.e., electronic) manner.

In addition in the radiology section's guidelines under "supervision and interpretation," the following describes the requirements for documentation:

Imaging may be required during the performance of certain procedures or certain imaging procedures may require surgical procedures to access the imaged area. Many services include image guidance, which is not separately reportable and is so stated in the descriptor or guidelines. When imaging is not included in a surgical procedure or procedure from the Medicine section, image guidance codes or codes labeled "radiological supervision and interpretation" may be reported for the portion of the service that requires imaging. Both services require image documentation and radiological supervision, interpretation, and report services require a separate interpretation.

Many offices are now transitioning to picture archiving and communication systems, or PACS, a healthcare technology for the short- and long-term storage, retrieval, management, distribution and presentation of medical images. For billing purposes, having the images stored on a PACS satisfies reporting requirements. In other words, the image wouldn't necessarily need to be included separately in the electronic health record. A separate report that satisfies communication standards is generally required. It is usually not sufficient to simply describe the findings in an E&M encounter note. However, if your practice does not have a PACS, copies of ultrasound images must still be maintained in the electronic health record or in the patient chart.

Q.  If an ultrasound is performed on a male, what must be evaluated for it to be considered a complete study?

A.  In order to bill a 76856 Ultrasound pelvic (nonobstetric), or real time with image documentation; complete evaluation & measurement (when applicable) of the urinary bladder, evaluation of prostate and seminal vesicles (visualized transabdominally), and any pelvic pathology (bladder tumor, enlarged prostate, free pelvic fluid, pelvic abscess) must be performed. A separate written report should comment on all the findings of these organs. If particular elements cannot be visualized, the reason should be documented.

Q.  Can I bill for both an abdominal ultrasound and pelvic ultrasound if the urologist evaluates the kidneys and bladder?

A.  You cannot bill for both a 76705 Ultrasound abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up) and a 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation, limited or follow-up (eg, for follicles) when each of these organs is evaluated. CPT® code 76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation, complete should be billed if the clinical history suggests urinary tract pathology, and evaluation of both kidneys & bladder.

Q.  How do I code for a dual energy X-ray absorptiometry (Dexa) scan and will it be covered?

A.  Dual energy X-ray (DXA) absorptiometry is a means of measuring bone mineral density. It is used to diagnosis osteopenia or osteoporosis. DXA is also effective in tracking the effects of treatment for osteoporosis and other conditions that cause bone loss. In urology, many physicians will recommend that prostate cancer patients receiving androgen deprivation therapy have a DXA scan.

For many third-party payers, there are policy limits in place that restrict the frequency of DXA scans on an individual. The same is true for Medicare. Medicare has established a national coverage determination (NCD) for bone density study procedures that address the type of procedures covered, qualified individuals, provider requirements and frequency limitations. Medicare carriers may or may not have a written local coverage determination (LCD) and/or articles outlining additional coding guidelines particularly for patients not addressed in the NCD. However, there is no specific coverage for men who have undergone long term hormone therapy. Claims will be denied if the medical policy limits have already been met. If the service requires additional study beyond these limits and you believe the study is medically necessary you should contact the insurer to discuss the case prior to rendering the service.

DXA, Bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) – use CPT® code 77080.
DXA, Bone density study, 1 or more sites; appendicular skeleton, (peripheral) (e.g., radius, wrist, heel) – use CPT® code 77081.
DXA, Bone density study, 1 or more sites; vertebral fracture assessment – use CPT® code 77086

For first-time screenings, your patient may or may not be covered by their insurance carrier. Depending on the patient's diagnosis, you may have to have them sign an Advance Beneficiary Notice (ABN) form, unless the scan shows osteoporosis in which case that is a covered diagnosis by Medicare. If a repeated scan is not positive for osteoporosis, then any repeats are still considered screens and the patient continues to be responsible if they signed an ABN. Please be sure to check your carrier's LCD list to see in fact what diagnosis codes are covered by your Medicare carrier.

Diagnosis codes that support medical necessity can and do vary by payer; therefore, it is important to contact your local insurer for coverage and coding guidelines to ensure accurate billing.