1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 28 RADIOLOGY

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Radiology Radiology: Branch of medicine that uses ______ energy to diagnose and treat patients Specialist in radiology: _________ (doctor of medicine) radiant Radiologist

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Radiology Subsections Diagnostic Radiology –Aorta & arteries Diagnostic Ultrasound Radiologic Guidance Breast, Mammography Bone/Joint Studies Radiation Oncology –Clinical Brachytherapy Nuclear Medicine

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Terms __________ views inside of body, projects onto television screen Live images by which physician can view function and structure of organ –Example: 71034, _____ x-ray with fluoroscopy Fluoroscopy Chest

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Magnetic Resonance Imaging MRI uses magnetic energy to view ___ tissue structures –Example: 72148, MRI of ______ spine canal (Cont’d…) soft lumbar

6. Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. MRI (…Cont’d) MRA—Magnetic Resonance Angiography—is application of MRI that provides visualization of blood flow, as well as images of normal and diseased blood vessels Figure: 28.12 Modified from Bradley WG, Daroff RB, Fenichel GM, Jankovic J: Neurology in Clinical Practice, ed 5, Philadelphia, 2008, Butterworth-Heinemann.

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Tomography or CT Tomography used to view _____ plane of body –Example: 70450, Tomographic scan of head or _____ (Cont’d…) single brain

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CT Scan of Lung Carcinoma (…Cont’d) A, A patient with right hilar lung carcinoma and mediastinal adenopathy showing the margins of the bones. B, The scan can be set to show the soft tissue. C, The lung organs can be shown by using additional scan settings. There is greater detail than would be obtained with conventional radiographs. (Courtesy of Bruce Porter, MD.)

9. Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Biometry Biometry: Application of statistical methods to biological facts –Example: 76516, Use of _________ echography in biometry of eye Ultrasound diagnostic non-invasive procedures are performed to determine composition and contours of ocular and orbital structures ultrasound

10. Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Planes of Body Figure: 28.1 Imaginary lines used as points of reference

11. Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Position and Projection _______ : Way in which patient placed ________: Path x-ray beam travels Position Projection

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Terminology Radiology uses a wide variety of terms and abbreviations specific to planes, positions, and projections

13. Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Component Coding Three component terms –__________ –________ –______ Professional Technical Global

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Professional Component (-26) Physician portion of service, includes –Supervision of ________ –___________ of results, including written report From Young AP, Proctor DB: Kinn's The Medical Assistant, ed 10, St. Louis, 2007, Saunders. technician Interpretation

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Technical Component (-TC) Technologist’s services Equipment, ___, and supplies From Long BW, Frank ED, Ehrlich RA: Radiography Essentials for Limited Practice, ed 4, St. Louis, 2013, Saunders. film

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Global Procedure Both professional and technical portions of radiology service If facility where procedure was performed owns the equipment and has a radiologist on staff who reads the report global service –No -TC –No -26

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Component Modifiers If only professional component of radiology service provided append ___ to code -26 (Cont’d…)

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Component Modifiers (…Cont’d) If only technical component was provided append ___ to code –-TC: HCPCS modifier used with CPT and HCPCS codes -TC

19. Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Global Procedure If both professional and technical components of radiology service provided, use __ modifier no (Cont’d…)

20. Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. For Example: Chest X-Ray (…Cont’d) Professional component: –71030-26 (Supervision and final report) Technical component: –71030-TC (Technician, supplies, equipment) Global procedure: 71030 (both professional and technical) (Cont’d…)

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Global Procedure (…Cont’d) Third-party payers usually reimburse –40% professional component –60% technical component –100% global procedure

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Contrast Material Statement “with contrast” implies _______ built into code injection (Cont’d…)

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Contrast Material (…Cont’d) Notes indicate codes for components –Example: 75893, venous sampling indicates “(For procedure, use 36500)” Oral or _____ contrast does not qualify for “with contrast” rectal

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Overview of Radiology Subsections Diagnostic Radiology Diagnostic Ultrasound Radiologic Guidance Breast, Mammography Bone/Joint Studies Radiation Oncology Nuclear Medicine

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diagnostic Radiology “Complete” in a code description in radiology section, means all views taken of specified body site Most standard radiographic procedures Codes often divided on whether contrast material used Codes further divided on ______ views number (Cont’d…)

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diagnostic Radiology (…Cont’d) Used to: –Diagnose disease –Monitor disease process—progression or remission

27. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diagnostic Procedures Include X-ray Computerized axial tomography (CAT or __ scan) Magnetic resonance imaging (MRI) Angiography Subdural hematoma CT of renal artery From Mettler FA: Essentials of Radiology, ed 3, Philadelphia, 2014, Saunders. From Mettler FA: Essentials of Radiology, ed 3, Philadelphia, 2014, Saunders. From Walsh PC, editor: Campbell's Urology, ed 8, Philadelphia, 2002, Saunders. CT

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Computerized Axial Tomography X-ray image taken in sections Computer reconstructs and ________ image enhances

29. Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Magnetic Resonance Imaging Uses magnetic fields to produce an image displayed on computer screen Codes of same area (e.g., spine) divided on whether or not _______ _______ used contrastmaterial

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Angiography Used to view vessel obstructions ___ injected into vessel Dye (Cont’d…)

31. Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Angiography (…Cont’d) Angiography of aortic arch and brachio-cephalic vessels (Cont’d…) Figure: 28.13 From Stimac GK: Introduction to Diagnostic Imaging, Philadelphia, WB Saunders, 1992, p 447.

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Angiography (…Cont’d) Radiologist uses angiography to diagnose vascular conditions Examples: –Malformations –Strokes –Myocardial infarctions

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Remember If fewer than total number of views specified in code provided: –Use ___, Reduced Service -52

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diagnostic Ultrasound Uses high-frequency sound waves to image anatomic structures Audible sound waves bounce off body tissues and then are recorded to give information about anatomy of an internal organ (Cont’d…)

35. Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Diagnostic Ultrasound (…Cont’d) Ultrasound showing a gallstone Figure: 28.14 From Goldman L, Schafer AI, editors: Goldman's Cecil Medicine, ed 24, Philadelphia, 2012, Saunders.

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Subheadings Subheadings of Diagnostic Ultrasound primarily based on ________ Example: –Head and Neck –Chest –Pelvis Many notes in subsection directing correct assignment anatomy

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Three Locations For Ultrasound Services 76506-76999: Radiology codes for ________ ultrasound services 93880-93998: Medicine codes for _______ studies 93303-93352: Medicine codes for echocardiography diagnostic vascular

38. Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Interventional Radiologist Combination radiologist and _______ Provides total procedure for cystography with contrast –Report 74430, X-ray portion and –51600 for _______ procedure, –Plus code for supply of contrast material (e.g., 99070 or HCPCS code) surgeon injection

39. Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Ultrasound Modes and Scans __-mode or A-scan technology— one-dimensional __-mode—one-dimensional measurement procedure with movement of trace to allow amplitude and velocity of moving echo- producing structures __-scan technology—two-dimensional Real-time scan A & B scan may be performed together (medical necessity documented) M A B

40. Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. A-Mode A = _________ Technique used to map structure outline Displays ___-dimensional image Amplitude one

41. Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. M-Mode M = ______ Technique used to display movement of structure Displays ___-dimensional image Motion one

42. Slide 42 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. B-Scan B = _________ Technique used to display movement of tissues and organs Known as ____ scale ultrasound Displays ___-dimensional image Brightness gray two

43. Slide 43 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Real-Time Scan Technique used to display both _______ and ______ with time of organ and tissues Displays ___-dimensional image structure motion two

44. Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Extent of Study Codes often divided on extent of study Example: Extent of scan as follows (Cont’d…)

45. Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Extent of Study (…Cont’d) Complete: Scans entire body Limited: Scans ___ of body, i.e., one organ Follow-up/repeat: ______ study of part of body that was scanned previously part Limited

46. Slide 46 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Radiologic Guidance, Breast, Mammography, Bone/Joint Studies, and Radiation Oncology Radiologic Guidance (77001-_____) –Fluoroscopic, computed tomography, magnetic resonance guidance, and other Breast, Mammography (_____-77059) –Such as screening, and computer-aided detection Bone/Joint Studies (77071-_____) –Such as bone density and joint survey Radiation Oncology (_____-77799) –Therapeutic use of radiation –Codes for both professional and technical services –Subheading divided based on treatment 77022 77051 77084 77261

47. Slide 47 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Radiation Oncology Initial consultation, prior to decision to treat, reported with E/M Consultation code –________: 99241-99245 –_______: 99251-99255 Follow consultation criteria: Document who and why Outpatient Inpatient

48. Slide 48 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Clinical Treatment Planning— Professional Component Includes: –Interpretation of special testing –Tumor localization –Determination of treatment volume (Cont’d…)

49. Slide 49 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Clinical Treatment Planning (…Cont’d) Choice of treatment method Determination of number of treatment ports Selection of treatment devices Other necessary procedures (Cont’d…)

50. Slide 50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Clinical Treatment Planning (…Cont’d) Clinical Treatment Planning consists of –Three types of treatment plans –For all patients requiring radiation therapy

51. Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Levels of Planning (77261-77263) ______ : One treatment area, one port or one set of parallel ports __________: Three or more ports, two separate treatment areas, multiple blocking Simple Intermediate (Cont’d…)

52. Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Levels of Planning (…Cont’d) _______: Complex blocking, custom shielding blocks, tangential ports, special wedges, or compensators, ____ or more treatment areas, special beams Unlisted procedure (77299) Complex three

53. Slide 53 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Simulation (77280-77293) Determines placement of treatment areas/ports for radiation treatment Does not include administration of _______ (Cont’d…) radiation

54. Slide 54 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Four Levels of Simulation (…Cont’d) ______ : One treatment area with one port or pair of ports __________: Three or more ports, two separate treatment areas, multiple blocking _______: Tangential ports, three or more treatment areas, complex blocking 3D: Computer generated three-dimensional image of tumor Simple Intermediate Complex

55. Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services (77295, 77300- 77370) Decision-making services of physicians –Treatment types –Dose calculation and _________ (dosimetry) –Development of treatment device Stereotactic Radiation Treatment Delivery (77371-_____) –Pay close attention to notes Delivers large dose to specific tumor site placement 77373

56. Slide 56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Radiation Treatment Delivery (77401-77525) Radiation (77401-77421) Neutron Beam (77422, 77423) Proton Beam (77520-77525) Technical component of actual delivery of radiation –MeV (electrons) –Neutrons –Protons

57. Slide 57 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Information Needed to Code Radiation Treatment Delivery Amount of radiation delivered Type of radiation—_______ (most common), neutron, or proton (Cont’d…) electron

58. Slide 58 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Information Needed to Code Radiation Treatment Delivery (…Cont’d) Number of –_____ treated (single, two, three or more) –_____ involved (single, three or more, tangential) –______ used (none, multiple, custom) Areas Ports Blocks

59. Slide 59 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Reporting Radiation Treatment Management (77427-77499) 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 Unless last 3-4 fractions are at the end of the treatment –Count the last 3-4 as an ________ fraction additional

60. Slide 60 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Clinical Brachytherapy (77750– 77799) Placement of radioactive material into or around site of tumor: –__________ (within body cavity) –________ (within tissues) (Cont’d…) From Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG: Clinical Oncology, ed 3, Philadelphia, 2004, Churchill Livingstone. Intracavitary Interstitial

61. Slide 61 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Source (…Cont’d) Radioactive element delivers radiation dose over time –Examples: _____, ribbons, or capsules –Ribbons: Seeds embedded on tape Tape cut to desired length controls amount of radiation and inserted into tissue (Cont’d…) Seeds

62. Slide 62 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Clinical Brachytherapy Codes Divided Based On (…Cont’d) Number of sources applied: –Simple: _-4 –Intermediate: 5-__ –_______: 11+ 1 10 Complex

63. Slide 63 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nuclear Medicine Placement of radioactive material into body and ____________ of emissions Used both for diagnosis and treatment –Example: Stress test (Cont’d…) measurement

64. Slide 64 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nuclear Medicine (…Cont’d) Codes divided primarily on organ system –Exception: “Therapeutic,” for radiopharmaceutical therapies

65. Slide 65 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Positron Emission Tomography (PET) 78811-_____ Based on _______ (such as skull base or chest) Non-invasive imaging procedure that assesses perfusion and level of metabolic activity in various organ systems PET imaging of Hodgkin’s lymphoma (the arrows indicate the site of the disease.) From Goldman L, Schafer AI, editors: Goldman's Cecil Medicine, ed 24, Philadelphia, 2012, Saunders. 78816 location

66. Slide 66 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 28 RADIOLOGY