Diagnostic Radiology. Contrast Enema 74270

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1 CPT Code* Update *(Current Procedural Terminology 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.) As of January 1,, radiology practices must use the new Current Procedural Terminology (CPT ) codes to report procedures and services rendered. 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 the service is provided. There is no grace period given to implement these changes (Pub , Medicare Claims Processing Manual, Transmittal 89). To assist in preparation for the new CPT coding year beginning January 1,, the ACR offers the following highlights of major code changes that will affect radiology practices. For a complete listing of CPT code changes, please see the CPT code book and CPT Changes : An Insider s View. Diagnostic Radiology Contrast Enema An editorial change will be made to code (Radiologic examination, colon; barium enema, with or without KUB) to clarify that this code should be used to report any type of contrast enema procedure, such as barium, water-soluble contrast, or other contrast media. Currently, the descriptor reads barium enema, and many mistakenly interpret this to mean that it can be used only for a barium enema contrast study. Therefore, the descriptor will be revised to list barium as one example of a contrast enema study that can be performed. Intraoperative Ultrasound Parenthetical statements following the intraoperative ultrasound guidance code, 76998, and the endovenous ablation therapy (EVAT) codes, , will be updated to indicate that it is inappropriate to report the intraoperative ultrasound guidance code in conjunction with EVAT procedures. Intraoperative ultrasound guidance is a component of EVAT studies and should not be reported in addition to EVAT codes. Interventional Radiology Diagnostic Percutaneous Aspiration (spine) A new spine aspiration code, (Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes) has been added to describe the percutaneous aspiration of fluid and/or cells for diagnostic purposes and to distinguish this diagnostic aspiration procedure from the therapeutic decompression procedure described by (Decompression procedure, percutaneous, nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar ). The current

2 descriptor for includes the term aspiration. This term will be deleted in to avoid any confusion. A cross reference notes that it is appropriate to report fluoroscopic or computed tomography guidance in addition to when performed. Cross References A number of cross references have been added to the CPT code book to clarify codes that should or should not be reported together. The following are just a few examples of the cross references to be added. For a complete listing of cross-reference updates, refer to the CPT code book and CPT Changes: An Insider s View. Insertion of Indwelling Tunneled Pleural Catheter The cross reference following the insertion of the indwelling tunneled pleural catheter code was revised to note that it should not be reported with one of the thoracentesis procedure codes, or The other codes currently listed (32551, 32560, 36000, 36410, 62318, 62319, 64450, 64470, 64475) have been deleted from the cross reference because they are separate procedures and do not include the insertion of an indwelling tunneled pleural catheter. Naso- or Oro-Gastric Tube Placement A statement following the naso- or oro-gastric tube placement code, 43752, has been added to note that the new neonatal and pediatric critical care codes or low birth weight intensive care service codes should not be reported in conjunction with Nuclear Medicine Non-imaging Gamma Probe Study A new code, 78808, was created to describe a nonimaging gamma probe procedure for which a radiopharmaceutical is prepared and injected. Currently in nuclear medicine, there is no code that describes an injection of a radiopharmaceutical without an associated imaging procedure. The physician work and technical component resources for code are different from the resources for code used during an interstitial injection prior to surgery for which a gamma probe may be used for localization of a sentinel node. Generation of Automated Data 78890, The generation of automated data codes and 78891, which are used to describe computer processing, are obsolete and will be deleted. As noted in the ACR s Nuclear Medicine Coding User s Guide 2008, p. 48, Computer processing required for nuclear medicine procedures has been included directly into the series codes; therefore, it is not appropriate to charge separately for computer processing in addition to the 78000

3 series codes. Neither the ACR nor the Society of Nuclear Medicine has recommended the use of codes or for a number of years. Radiation Oncology Remote Afterloading High Intensity Brachytherapy 77785, 77786, The remote afterloading high intensity brachytherapy codes , differentiated by the number of source positions or catheters, will be deleted in and replaced by three new codes, 77785, 77786, and 77787, differentiated by the number of channels (i.e., 1 channel, 2 to 12 channels, or more than 12 channels). The CPT codes 77785, 77786, and for high dose rate (HDR) brachytherapy reflect the most current practice and better define the physician work involved in these procedures. Placement of Radiotherapy Afterloading Catheter 19296, The descriptor for the placement of radiotherapy afterloading catheter codes and has been revised to designate that these procedures refer to an expandable single or multichannel catheter. The addition of (single or multichannel) differentiates these codes from code 19298, which describes the interstitial placement of multiple tube and button type catheters (CPT Changes: An Insider s View ). New Subsection on Stereotactic Radiosurgery (Cranial/Spinal) A new subsection has been created in the CPT code book to describe different types of stereotactic radiosurgery (SRS), such as cranial and spinal. New codes were created to describe SRS performed by the surgeon for cranial lesions ( ) and spinal lesions (63620, 63621). Therefore, cross references under the new SRS codes point to the appropriate stereotactic radiation treatment management codes to be used by the radiation oncologist in conjunction with the SRS and SBRT codes. The same physician should not report both the stereotactic radiosurgery services and the radiation treatment management services. Surgeons should report the surgical code ( , 63620, or 63621), and the radiation oncologist, when involved, should report for cranial lesions or for extracranial lesions. The SRS introductory section also clarifies that for lesions that are neither cranial nor spinal, codes and are used for intensity modulated beam delivery plan and treatment (IMRT), and code is used for stereotactic body radiation therapy (SBRT).

4 Category III Code Changes Category III codes are temporary codes that are used to track emerging technology and procedures. Category III codes are archived five years from their publication date in the CPT book, unless it is requested that the code be converted to Category I status or a request for extension of the code is made. The following Category III codes are set to be archived as of December 31, 2008: Code 0027T, which describes an endoscopic lysis of epidural adhesions study, will be deleted. The unlisted nervous system procedure code, 64999, should be reported in when this type of procedure is performed. Code 0028T, which describes a dual energy X-ray absorptiometry body composition study, and 0060T, which describes an electrical impedance scan of the breast, also will be deleted in. The unlisted diagnostic radiographic procedure code, 76499, should be reported in when one of these procedures is performed. Category II Code Proposed Changes for A number of new Category II codes have been created and are listed in the CPT code book and on the AMA Web site. These codes are intended to facilitate data collection about the quality of care rendered and are used in the Physician Quality Reporting Initiative (PQRI). However, the new codes only be reported if approved for use in the Medicare Physician Fee Schedule (MPFS) Final Rule calendar year (CY). Look for CMS to provide further guidance on PQRI measurement reporting on the CMS Web site in December (worksheets and other specifications), and continue to visit the ACR and CMS Web sites for updates. See for a complete listing of PQRI measurements available for use. For Category II codes created in, go to the AMA Web site at To learn more about the Physician Quality Reporting Initiative, visit the CMS Web site at and on the ACR Web site at Carotid Imaging Measure #11 Changed The use of measure #11 is no longer limited by a diagnosis of ischemic stroke or transient ischemic attack. All carotid imaging studies should be reported either with 3100F when reference to measurements of distal internal carotid diameter for stenosis measurement is made or 3100F-8P when reference to measurements is not made. The 1P modifier used to report a medical exclusion will not be allowed for measure #11 in.

5 Mammography Five mammography measures were proposed, but only one measure is listed for PQRI in the Medicare Physician Fee Schedule Final Rule Inappropriate Use of Probably Benign Assessment. Codes 3340F, 3341F, 3342F, 3343F, 3344F, 3345F, and 3350F are to be used in for reporting this measure. The CPT II codes correlate to the Breast Imaging Reporting and Data System (BIRADS )* Assessment Categories (see table below). If participating in PQRI, each claim for a screening mammogram should include one of the CPT II codes indicating the assessment category that was given on the final report. This allows CMS to determine whether the quality code was left off or if the assessment category was a code other than a BIRADS 3 code. The mammography Category II codes correlate to the BIRADS Assessment Categories, as noted in the following table. Category II Code BIRADS Code 3340F F F F F F F 6 *BI-RADS is a quality assurance guide designed to standardize breast imaging reporting and facilitate outcome monitoring. The four mammography measures not included in PQRI are Communication of Suspicious Findings to a Practice, Communication of Suspicious Findings to a Patient, Assessment Category Data Collection, and Reminder System for Mammograms. Do NOT report the CPT II codes on claims for these measures. Computed Tomography (CT) Radiation Dose Reduction Code 6040F was created to track documentation of the appropriate use of radiation dose reduction devices or manual techniques for appropriate moderation of exposure during CT procedures. However, the CT Radiation Dose Reduction measure was not included in the CY Final Rule. Practices should not report the 6040F code on claims. Fluoroscopy Exposure Time Code 6045F was created to identify those procedures that record fluoroscopy exposure or fluoroscopy time in the final report when fluoroscopy is used. Code 6045F should be reported with modifier 8P to identify studies that do not document fluoroscopy exposure

6 or fluoroscopy time in the final report. A listing of CPT codes that use fluoroscopy can be found in the Radiology Physician Performance Measurement Set document (updated September 2008) on the AMA Web site. Please see the measure specifications at Nuclear Medicine A new nuclear medicine Category II code, 3570F, has been added to the PQRI measure set to identify instances when the final report for a bone scintigraphy procedure includes physician documentation that states that the nuclear medicine study was correlated to existing relevant imaging studies. In instances where no existing relevant imaging study is available or the patient did not have a previous relevant imaging study, modifier 3P should be reported with code 3570F. A second nuclear medicine measure, Communication of Fracture Risk (CPT II codes 3572F, 3573F), has not been included in the PQRI. Codes 3572F and 3573F should NOT be reported on claims for. Radiation Oncology Three new measures are potentially reportable by radiation oncologists in. These are Pain Intensity Quantified, Plan of Care for Pain, and Normal Tissue Dose Constraints Specified. It is recommended that the first two measures, Pain Intensity and Plan of Care for Pain, be reported together, however, this is not a requirement. The associated codes for these measures are 1125F and 1126F for Pain Intensity Quantified, and 0521F for Plan of Care. The Normal Tissue Dose Constraints associated code is 0520F. Three other new radiation oncology measures with associated CPT II codes will not be in PQRI : Cancer Stage Documented (3300F and 3301F), Pathology Report (3317F and 3318F), and Treatment Summary Communicated (5020F). A number of codes used by radiation oncologists will be deactivated in, either because the measure was dropped in or the codes were revised. Measure #74, Radiation Recommended, was removed from the PQRI list; therefore, codes G8378, G8379, and G8383 should not be reported. Codes for Measure #71, Hormonal, are revised for (see list below for details). Measure #103, Treatment Options, also has been dropped; therefore, code 4163F should not be reported on claims for this measure. Summary Begin reviewing the measurement sets now to work out any problems in reporting and to ensure that your claims will be processed appropriately for the specified reporting periods.

7 The AMA has implemented a number of new CPT II codes, but only a handful of these codes were approved for use in. The following tables identify the active codes. Also note, several measures that were available in 2008 have been deleted in, and some measures have been revised. Table 1. Codes Reportable in for Measures Relevant to Radiology/Radiation Oncology (listed in the Final Rule) # CODE MODIFIERS ALLOWED EFFECTIVE DATE SET NOTES F 8P 1/1/07 Stroke CT/MRI Reports Modified in F 1/1/07 Stroke CT/MRI Reports F 1/1/07 Stroke CT/MRI Reports F 8P 1/1/07 Stroke, Rad Carotid Imaging Modified in F 1P,8P 1/1/07 Perioperative Timing of Antibiotics-Ord Phys F 1/1/07 Perioperative Timing of Antibiotics-Ord Phys F 1/1/07 Perioperative Selection of Antibiotic F 1P,8P 7/1/07 Perioperative Selection of Antibiotic F 1/1/07 Perioperative Discontinuation of Antibiotic F 1/1/07 Perioperative Discontinuation of Antibiotic F 1P,8P 1/1/07 Perioperative Discontinuation of Antibiotic F 1P,8P 1/1/07 Perioperative VTE Prophylaxis F 1P,2P,8P 1/1/07 Osteoporosis Comm Following Fracture F 1P,2P,3P,8P 1/1/07 Osteoporosis Mgmt Following Fracture F 1P,2P,3P,8P 1/1/07 Osteoporosis Mgmt Following Fracture F 1P,2P,3P,8P 1/1/07 Osteoporosis Mgmt Following Fracture F 1/1/08 Oncology Hormonal

8 # CODE MODIFIERS ALLOWED EFFECTIVE DATE SET NOTES F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1P,2P,3P,8P 1/1/08 Oncology Hormonal F 1P,8P 1/1/08 Critical Care Max Sterile Barrier Technique F 1P,3P 1/1/08 Prostate CA Bone Scan Overuse - Staging F 1/1/08 Prostate CA Bone Scan Overuse - Staging F 1/1/08 Prostate CA Bone Scan Overuse - Staging F 1/1/08 Prostate CA Bone Scan Overuse - Staging F 1/1/08 Prostate CA Bone Scan Overuse - Staging F 1/1/08 Prostate CA Bone Scan Overuse - Staging F 1P,2P,8P 1/1/08 Prostate CA Adjuvant Hormonal F 8P 1/1/08 Prostate CA 3D Radiotherapy F 10/1/07 Prostate CA 3D Radiotherapy Modified 10/1/ F 10/1/07 Prostate CA 3D Radiotherapy Modified 10/1/ F 8P 1/1/08 Radiology Fluoro Time Recorded

9 # CODE MODIFIERS ALLOWED EFFECTIVE DATE SET NOTES F 8P 1/1/08 Oncology Plan of Care for New Pain measure for F 1/1/08 Oncology Plan of Care for 143A/143B Pain reported together F 1/1/08 Oncology Plan of Care for Pain F 1/1/08 Oncology Pain Intensity Quantified New measure for F 1/1/08 Oncology Pain Intensity 143A/143B Quantified reported together F 3P,8P 10/1/08 NUC MED Correlation of Bone Studies New measure for F 8P 10/1/08 Oncology Tissue Dose Constraints New measure for F 4/1/08 Radiology Inappropriate Use New BIRADS 3 measure for F 4/1/08 Radiology Inappropriate Use BIRADS F 4/1/08 Radiology Inappropriate Use BIRADS F 4/1/08 Radiology Inappropriate Use BIRADS F 4/1/08 Radiology Inappropriate Use BIRADS F 4/1/08 Radiology Inappropriate Use BIRADS F 4/1/08 Radiology Inappropriate Use BIRADS 3

10 Table 2. Codes Associated with PQRI Measures Relevant to Radiology/Radiation Oncology/Nuclear Medi cine NOT to Be Used in (according to the CY Final Rule) CODE # F- 1P EFFECTIVE DATE SET 1/1/07 Stroke, Rad F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal NOTES REGARDING PQRI USE Carotid Imaging Modifier 1P not allowed in : 3100F without modifier is allowed Measure codes revised for Measure codes revised for revised for Measure codes revised for Measure codes revised for ed for Measure codes revised for Measure codes revised for ed ed ed ed n 009 Recommended n 009 Recommended Measure dropped in Recommended Initial Evaluation Measure dropped in F 1/ 1/08 Oncology Hormonal Measure codes F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1/1/ 08 O ncology Hormonal Measure codes revis F 1/1/08 Oncology Hormonal F 1/1/08 Oncology Hormonal F 1/ 1/08 Oncology Hormonal Measure codes revis for F 1/ 1/08 Oncology Hormonal Measure codes revis for F 1/ 1/08 Oncology Hormonal Measure codes revis for F 1/ 1/08 Oncology Hormonal Measure codes revis for 74 G8378 1/ 1/08 Oncology Rad Measure dropped i 2 74 G8379 1/ 1/08 Oncology Rad Measure dropped i 2 74 G8383 1/1/08 Oncology Rad F 1/1/08 Prostate CA F 1/1/08 Prostate Treatment CA Options F 1/1/08 Radiology CT Dose Reduction Measure dropped in New measure not included in

11 # CODE EFFECTIVE DATE SET NOTES REGARDING PQRI USE ONC1 3300F 1/1/08 Oncology Cancer Stage Documented New measure not included ONC1 3301F 1/1/08 Oncology Cancer Stage New measure not Documented included ONC F 1/1/08 Oncology Pathology Report New measure not included ONC F 1/1/08 Oncology Pathology Report New measure not included NM2 3572F 10/1/08 NUC Communication New measure not MED of Fracture Risk included NM2 3573F 10/1/08 NUC Communication New measure not MED of Fracture Risk included NMA 4181F 1/1/08 No measure No measure associated NMA 4182F 1/1/08 No measure No measure associated ONC6 5020F 10/1/08 Oncology Treatment New measure not Summary included Communicated - RO RAD4 5060F 1/1/08 Radiology Mammography - New measure not Communication included to Practice RAD5 5062F 1/1/08 Radiology Mammography - Communication New measure not included to Patient Reporting Options In 2008, CMS implemented two alternative report ing options: alternative reporting periods and measure group reporting. CMS also intends to expand on these reporting options for. A measure group is a s ubset of PQRI measures that have a particular clinical condition or aspect of care in common. Each measure group contains at least four PQRI measures and may be reported through claims-based or registry-based data submission. All measures within that group must be reported. An alternative period is available when reporting measure groups. In place of reporting the full year, a provid er can report for only six months by repo rting 30 consecutive cases or an 80 percent patient sample from services provided from July 1 through December 31,. The bonus payment for successful reporting of measure groups will be 2 percent of Medicare allowed charges for the six-month period.

12 The alternative reporting period optio n may apply to few radiology practices, since the only measure group for that radiologists may use is the perioperative care m easure group. The perioperative care measures may app ly to interventional radiologists who perform procedures such as kyphoplasty or vertebroplasty. Registry-Based Reporting CMS has implemente d registry -based reporting a s an additional method for PQRI participation. Registries must collect physician-submitted data and must be able to calculate at le ast three approved PQR I measures. T he registry should provide for reporting of individual measures or m easure groups. Currently, there are no CMS- qualified registries for radiology measure reporting; however, the ACR is testing the General Radiology Improvement Database (GRID) for this kind of use in the future. Check the AC R Web site periodically for information on the ACR GRID project. C ontact Judy Burleso n, Director of Met rics, at jburleson@acr.org or call , for questions related to PQRI reporting.