1. Radiology
Radiology

2. CPT®
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3. Objectives Diagnostic coding Terminology Guidelines
Modifiers specific to radiology
Materials and equipment
In this lecture, we will discuss selecting the appropriate diagnosis for the service, terminology pertinent to radiology, the guidelines at the beginning of the section, as well as procedure specific guidelines throughout the section, modifiers specific to radiology, and we will touch on some of the materials and equipment used in radiology.

4. Diagnosis Coding Code the definitive diagnosis
Code signs and symptoms if no definitive diagnosis is available
Diagnostic tests
Code sign or symptom that prompted the test
Do not code questionable, rule out, or probably diagnoses.
Routine radiology
Z01.89 Radiological examination, NEC
Although we have discussed ICD-10-CM coding in the beginning of the course, it is important to review a few of the ICD-10-CM guidelines prior to getting into the procedural coding for Radiology. Diagnosis coding is important step to get correct because it supports medical necessity for the services rendered.
When a radiology service is ordered, typically the diagnosis will be a sign or symptom that concerns the provider, such as chest pain for a chest X-ray. If this is all you have at the time of the order, you will code chest pain as the diagnosis; however, if the interpreting physician has already read the film and provided a definitive diagnosis, such as lung cancer, the lung cancer would be reported as the diagnosis instead of the chest pain. It is important to remember, in physician coding, coding questionable diagnosis is not allowed. If the patient is getting a routine X-ray without a specific symptom or diagnosis, the diagnosis code reported should be Z01.89.

5. Terminology Position – how the patient is placed
Projection – the path of the X-ray beam
Now, let’s turn to our CPT® coding manuals, and discuss some terminology. It is important for a coder to understand the different anatomical planes, anatomical directions, and positioning in radiology. Turn with me to the beginning of your CPT® books and locate Figures 1A through 1C which shows different body planes and aspects. Remember, a position is how the patient is placed during the X-ray and the projection is the path of the X-ray beam. We will look at some examples in a minute. 5

6. Body Planes
Frontal (Coronal) – divides body into front (anterior) and back (posterior) portions
Sagittal – divides the body into right and left portions
Midsagittal (Medial) – sagittal plane passing through the midline to have equal portions in right and left
Transverse (Horizontal) – divides the body into top (superior) and bottom (inferior) sections
When discussing the body planes, we look at the body in anatomical positions, which is erect with feet slightly apart and palms facing forward, with thumbs pointing away from the body. Some body planes include the frontal plane, also referred to as the coronal plane, which divides the body into front, or anterior, and back, or posterior, sections. The sagittal plane divides the body into right and left portions. The midsagittal or medial plane divides the body into equal portions on the right and left. The transverse plane divides the body into top, or superior, and bottom or inferior, sections. 6

7. Body Directions
Frontal – anterior/ventral (front) portion of the body (eg, 71010)
Dorsal – posterior (back) portion of the body
Superior – above, or at the top
Inferior – below, or at the bottom
Lateral – to the side (eg, 71020)
Medial – at the middle
Supine – Face up or palm up
Prone – Face down or palm down
Erect – Standing up (eg, 73565)
Decubitus – Lying down (eg, 74020)
Some directional terms to review include frontal, which refers to the front or anterior portion of the body, and dorsal, which refers to the back or posterior portion of the body. Superior refers to the top of the body or above, and Inferior or Caudal means the bottom of the body or below. Lateral is to the side, so your arms are lateral to your midline. Medial means toward the middle, so your abdomen is medial to your arms. Supine is facing up, and prone is facing down. Erect, as we discussed in the anatomical position, is standing up. Decubitus is lying down. 7

8. Radiologic Projections
Oblique – slanting, neither frontal or lateral (eg, 71022)
Lateral – side view, X-ray beam travels through the side of the body (eg, 71035)
Anteroposterior – X-ray beam enters the body through the front and exits through the back (eg, 74000)
Posteroanterior – X-ray beam enters the body through the back and exits through the front (eg, 71101)
Cone – focused or spot view (eg, 74010)
Some important terms in radiologic projections include Oblique, which is where the body is at a slanted position; it does not face frontal or lateral, but at an angle. Lateral when referring to the projection refers to the X-ray beam traveling through the side of the body. Anteroposterior is when the projection is from front to back, or anterior to posterior. Posteroanterior is when the projection is from back to front, or posterior to anterior. A cone view is a focused or spot view. 8

9. Additional Terms
Proximal – closer to the point of attachment to the body
Distal – away from the point of attachment to the body
Flexion – bending (eg, 72120)
Extension – straightening
Some additional terms we need to know include proximal, which is closer to the point of attachment to the body. For instance, the elbow is proximal to the wrist because the shoulder is the attachment of the limb to the body, and the elbow is closer to the shoulder than the wrist. Distal is away from the point of attachment; therefore, the wrist is distal to the elbow. That is to say, the wrist is further from the shoulder (which is our point of attachment) than the elbow. Flexion is the bending of a joint to reduce the angle of the joint. Extension is straightening the joint which increases the angle of the joint. 9

10. Subsections Diagnostic Radiology (Diagnostic Imaging) (70010-76499)
Diagnostic Ultrasound ( )
Radiologic Guidance ( )
Breast, Mammography ( )
Bone/Joint Studies ( )
Radiation Oncology ( )
Nuclear Medicine ( )
Now, let’s turn to our CPT® coding manuals to the Radiology Section. As you look at the table of contents for Radiology, you will see the major subsections of Diagnostic Radiology, Diagnostic Ultrasound, Radiologic Guidance, Mammography, Bone & Joint Studies, Radiation Oncology, and Nuclear Medicine. We are going to cover some of these today, but first, let’s look at the guidelines for the radiology section. 10

11. Guidelines
Separate procedures – integral part of another procedure unless carried out separately
Example: & 76873
Unlisted procedures
Check Category III codes
Special Report
As a reminder, separate procedures are procedures considered an integral component to a more extensive procedure and are not coded separately. In the event the procedure is carried out independently or considered unrelated to another procedure, it can be coded separately. There are only a few codes listed as “separate procedure” in the radiology section.
Next in your guidelines, there is a list of the “unlisted procedure” codes used for Radiology. Before you use an unlisted code, make sure there is not a code for that procedure in the category III codes. Remember, the Category III codes list codes for new technology, which is very common in radiology.
Any time you use an “unlisted procedure” code you want to include a “special report.” Information you should include in the special report is listed in the guidelines under “Special Report” and includes an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort, and equipment necessary to provide the service. You may also want to make a note to include a procedure code similar to the procedure performed so that the insurance company has a point of reference. 11

12. Guidelines Supervision and Interpretation (S & I)
Interventional radiologic procedures
Report two codes:
Surgical code from the surgery section; or service code from the medicine section
Radiologic supervision and interpretation code from the radiology section.
Next in the guidelines, we have supervision and interpretation, often referred to as S & I codes. Interventional radiologic procedures are used to diagnose and treat conditions using invasive procedures. When a procedure requires radiologic guidance, a code from the surgery or medicine section is reported along with the supervision and interpretation code from the radiology section. When the same physician provides both the surgical procedure and the radiologic guidance, that physician will report both codes. When a physician performs the surgery, and a radiologist performs the supervision and interpretation, each will report the code for their portion of the service. 12

13. Guidelines Administration of Contrast Material
Contrast material administered intravascularly, intra-articularly or intrathecally
With contrast
Oral and/or rectal contrast does not qualify
Without contrast
Supply of contrast material is not included in radiologic procedure (eg, A4641, A4642, etc.)
Written Report(s)
Perhaps one of the most important guidelines to point out is administration of contrast material(s). The phrase “with contrast” used in the codes for procedures performed using contrast for imaging enhancement represents contrast material administered intravascularly (using a vein), intra-articularly (in a joint), or intrathecally (which is within a sheath, or within the subarachnoid or subdural space). The codes will state “with contrast” in their description. At the end of the instructions for contrast material, you may want to highlight or underline the sentence stating, “Oral and/or rectal contrast administration alone does not qualify as a study ‘with contrast.’”
As you code for contrast imaging, you may also need to code an additional procedure. Make sure you watch for parenthetical instructions under the imaging codes to see if another procedure should also be reported.
Contrast material is a substance or material that “lights up” what is being studied so that it can be visualized. Oral contrast is either barium or a mixture of fruit juice and an iodine-containing liquid. Some patients are allergic to iodine; therefore, other substances are used. Or they may have the patient use a Barium enema. In these cases it would not be appropriate to use a code that states “with contrast.” Keep in mind, the supply of contrast material is not included in the radiologic procedure and can be reported separately, typically with a HCPCS level II code.
The final note in the guideline section is about the written report provided by the radiologist. It should be signed and is the documentation for the radiologic procedure or interpretation. 13

14. Modifiers Technical Component (TC) Equipment Overhead Supplies Room
Gowns
Professional Component (26)
Reading and interpretation
Before we continue on to talk about the subsections, we need to review a few modifiers.
When the value of an X-ray is set they look at several components. You have the cost of the equipment, the overhead of the supplies and resources such as the room, the electricity, the little gowns they make you wear, and the salary of the technician that positions you in the most awkward ways and then tells you to not move and hold your breath while they perform the service. This is all factored into the fee and called the technical component.
For the procedure to have any real value it needs to be read or interpreted by a radiologist or other physician. This is the professional component. A radiologist is a doctor that is trained on how to interpret the images made by the procedures. When a code is assigned a dollar value it includes both the Technical and the professional components. Generally the payers pay 40 percent of the fee for the professional and 60 percent for the technical.
When you are only reporting the technical component, which is not typical in physician coding, you would append a modifier TC. When you are only reporting the professional component, which is common in physician coding, you would append a modifier 26. When you are reporting both the technical component and the professional component, you would bill “global” and would not use a modifier.
For example, many orthopedic offices have their own X-ray equipment, employ radiology technicians to use the equipment, and the providers are trained to read the X-rays. In this case, the radiologic procedures performed and read in the office would be reported without a modifier since they are performing both the technical portion and the professional portion of the exam.
Another example would be when a patient has an X-ray at a hospital. The hospital owns the equipment and employs the technicians. The physician or radiologist reading and interpreting the X-ray would append modifier 26 to the services to indicate only the professional service was performed.
There is a small amount of room at the bottom of the last page of the guidelines. You might want to take a minute and make a few notes about the use of these modifiers TC and 26 for you to have a quick and handy reference. 14

15. Number of Views More than # views
Additional views are taken, above the number in the code
No other more specific code is reported
Only that service should be reported.
Example
Radiologic examination, chest, complete, minimum of 4 views
If 5 views are taken, this would still be the appropriate CPT® code
The last item I want to discuss before moving into the subsections is number of views. Many of the X-ray codes mention a number of views, such as two views, or minimum of four views. When a code descriptor mentions a “minimum” number of views, at least that number of views must be taken to report the code. In addition, if more views are taken, and there is no more extensive procedure code to report the additional views, only that service should be reported. Here we see an example of a Radiologic examination of the chest, complete, minimum of 4 views. If 4 views are taken, this code is reported. If 5 views are taken, the code for 4 views is still reported since there is no more extensive CPT® code. It might be helpful for you to go through the radiology section and underline the # of views in each CPT® code descriptor so it stands out to you. 15

16. Diagnostic Radiology (Diagnostic Imaging)
Anatomical organization
Radiologic procedures include:
Standard X-rays
MRIs
CTs
Now, let’s move on to the subsections. First, we will look at diagnostic imaging. Diagnostic imaging is organized by anatomical location. Working down the skeletal structure from head to extremities, and then moving into the body and looking at organ systems within the body. The procedures in the anatomical subsections include standard radiologic exams such as a chest X-ray, or an X-ray of the arm, and MRIs and CTs, both of which can include contrast studies. MRI stands for magnetic resonance imaging and uses an external magnetic field to produce a two-dimensional view of an internal organ or structure. CT stands for Computed Axial Tomography and produces slices of the body to create a three dimensional image. In the index, MRI is found under magnetic resonance imaging, and CT is found under CT scan. 16

17. Diagnostic Radiology (Diagnostic Imaging)
Code Selection:
Anatomical location
Type of procedure
Number of views
Type of view (AP, PA, etc)
Laterality (unilateral, bilateral)
Contrast material
When selecting a code, you will need to identify the anatomical location, the type of procedure (is it a standard X-ray, CT, or MRI?), number of views taken, the type of view taken (is it anteroposterior, or maybe oblique), the laterality of the procedure (is it unilateral or bilateral), and the use of contrast material.
With this information you are ready to locate the specific code. You can use the index and look up the type of imagery, such as X-ray, CT Scan, or Magnetic Resonance Imaging (MRI). 17

18. Examples Procedure: X-ray of the foot Index X-ray
Radiology Section
Radiologic examination, foot; 2 views
complete, minimum of 3 views
For example, let’s look for X-ray of the foot. Turn to the index and look up X-ray, then follow down the alphabetical list to foot to find the range of codes. Turn back to the radiology section and look for that range of codes. When you locate the codes, you can decide which code applies based on the number of views.
Not all coders use the index. Sometimes it is just as easy to turn to the anatomical area subsection and read down to find the correct description. Either way is correct. What is important is that you read the code description carefully and make sure it is the correct code for the services performed. 18

19. Examples Procedure: CT abdomen, with contrast Index
Computed Tomography (CT) See CT Scan; specific Anatomic Site
CT Scan with Contrast
Abdomen…………………… , 74177
Radiology Section
Computed tomography, abdomen; with contrast material(s)
Now, let’s look up a CT scan. You will find if you look up the word Computed Tomography in the Index, you are directed to see CT Scan; specific anatomic site. In the Index, under CT Scan, we find with contrast, then abdomen, which leads us to and The descriptions in the Radiology Section of CPT® will help us determine which code to use.  19

20. Examples
74150 Computed tomography, abdomen; without contrast material with contrast material(s) without contrast material, followed by contrast material(s) and further sections Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) with contrast material(s) without contrast material(s), followed by contrast material(s) and further sequences CT
MRI
You might want to take some time now to place brackets around and label the sections of CTs and MRIs. Reading through these codes and taking the time to highlight and make note of important information contained in the code descriptions as well as in the parenthetical statements will be time well invested in making your book easy to use. 20

21. Heart Heart Stress Cause the heart to work harder Cardiac MRI
Physiologic evaluation of the cardiac function
Velocity flow mapping
Cardiac CT
Coronary calcium
Congenital heart disease
Now that you know the information you need and how to locate a code in this section, let’s look at some of the anatomical subsections with specific guidelines.
Turn in your CPT® book to the subsection for the heart. Here, you will see paragraphs of information. These paragraphs contain instructions on how to use the codes within this anatomical subsection.
It’s important to note when the word “stress” is used in cardiac imaging, it is referring to conducting the test while or after administering a pharmacologic substance to cause the heart to work harder, in effect “stressing” the heart. Cardiac MRIs are performed for physiologic evaluation of the cardiac function. For MRIs, you will need to know if velocity flow mapping was used.
For CTs, you may need to know what the assessment was for, such as evaluating coronary calcium or possible congenital heart disease. 21

22. Vascular Procedures Aortography – imaging of aorta and branches
Aorta and arteries
Aortography – imaging of aorta and branches
Angiography – imaging of arteries
Veins and lymphatics
Lymphangiography – visualization of lymphatics
Splenoportography – injection of contrast into the spleen to visualize the port vessel of the portal circulation
Venography – imaging of veins
Just below the heart subsection is a subsection for vascular procedures. This subsection is further divided into the aorta and arteries, veins and lymphatics, and transcatheter procedures.
Codes in the subsection for aorta and arteries include the supervision and interpretation codes for aortography, which is imaging of the aorta and its branches; and angiography, which is imaging of the vessels. For both an aortography and an angiography, a catheter is introduced into the vessels. The actual procedures are reported with codes in the cardiovascular and medicine sections of CPT®. There are lengthy guidelines in this subsection. Take time to read and underline key words in the guidelines. Codes for aortography and angiography are selected based on the location, laterality, and whether the catheterization is selective or non-selective. For Aortography, thoracic, you may see “Arch exam” in the physician’s documentation.
The next subsection is the Veins and lymphatics. Please note that the guidelines to diagnostic venography are identical to those for the Aorta and arteries. Take a minute to read them and highlight the key points. This would be a good place to bracket like procedures. Lymphangiography is the visualization of lymphatics; splenoportography is when contrast is injected into the spleen to visualize the port vessel of the portal circulation, and can be used in the diagnosis of portal hypertension; venography is imaging of the veins. 22

23. Vascular Procedures Transcatheter procedures
Supervision and interpretation codes
Code with codes from:
Cardiovascular section
Medicine section
Next, we see a subsection for the supervision and interpretation of transcatheter procedures. As with the codes from the prior two subsections, codes from this section are reported for the supervision and interpretation of procedures coded from the cardiovascular section and medicine section of the CPT® coding manual.
In your instructions, make sure you read through and underline or highlight the services included in transcatheter procedures. Also included in your instructions is a note to say diagnostic angiography can be specifically included in the code descriptor, and if not included in the descriptor, should be reported separately. 23

24. Other Procedures
Fluoroscopy (separate procedure), up to one hour physician or other qualified health care professional time, other than or (e.g., cardiac fluoroscopy)
76001 Fluoroscopy, physician or other qualified health care professional time more than 1 hour, assisting a nonradiologic physician or other qualified health care professional (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy)
Note: Do not report or in conjunction with 33957, 33958, 33959, 33962, 33963, 33964
One of the most common procedures in the “Other Procedures” section is Fluoroscopy. Be sure to underline the time references in the codes for fluoroscopy. 24

25. Diagnostic Ultrasound
High frequency sound waves to look at organs and other structures inside the body
Used to view:
Heart
Blood vessels
Kidneys
Other organs
Fetus (during pregnancy)
The next major section we come to is Diagnostic Ultrasound. Ultrasound uses sound waves to visualize internal structures such as muscles, tendons, and organs. The images can then be used to measure the size, and can also be used to observe the movement and functioning of structures such as the heart, blood vessels, etc. During pregnancy, ultrasound is used to view the fetus. Ultrasound is also used for guidance in various procedures.

26. Diagnostic Ultrasound
Required:
Permanently recorded images with measurements
Final written report for the patient’s medical record
Exception – biometric measure
In the instructions for diagnostic ultrasounds, we are instructed 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, permanently recorded images are not required. A final, written report should be issued for inclusion in the patient’s medical record.

27. Diagnostic Ultrasound
Anatomic regions
Complete – each element listed in parenthesis within the code description
Limited – reported if less than complete is performed.
Not reported together
Definitions
A-mode
M-mode
B-scan
Real-time scan
If less than the required elements for a “complete” exam are reported, the “limited” code for that anatomic region should be used once per patient exam session. A limited exam and complete exam should not be reported together because a limited exam is inclusive to a complete exam.
A Doppler study is a type of ultrasound that can penetrate solids or liquids. It is very useful in imaging the flow of blood. It can create either shades of gray images or can also be processed through a computer to produce a color image. The use of Doppler imaging is separately reportable except when used alone for anatomic structure identification in conjunction with real-time ultrasound.
At the end of the subsection guidelines for Diagnostic Ultrasound, you will see definitions for A-mode, M-mode, B-scan, and Real-time scan. Review these definitions as they are pertinent to coding ultrasounds. You may also want to go through the ultrasound procedures and underline these terms so they stand out in the code descriptors. 

28. Ophthalmic Ultrasound
A-scan – look straight ahead
B-scan – look in many directions
Biomicroscopy – slit lamp exam
Cataracts
Macular degeneration
Retinal detachment
Corneal Pachymetry – determine corneal thickness
Ophthalmic Ultrasound, in the Head and Neck anatomical subsection, includes Biometric A-scan, Biomicroscopy, Quantative A-Scan, and corneal pachymetry. For an A-scan, you will look straight ahead. For a B-scan, you will look in many different directions. A biomicroscopy is a slit lamp exam, which is a low power microscope combined with a high-intensity light source that can be focused to shine in a thin beam. This test may detect diseases such as cataracts, macular degeneration, retinal detachment, and other eye diseases. A corneal pachymetry is a test to determine corneal thickness. Topical anesthesia is required for corneal pachymetry because the probe must touch the corneal surface.

29. Pelvis Ultrasound Obstetrical Pregnant uterus 76801 – 76817
Review definitions in guidelines
Fetal
76818 – 76828
Look for what specifically is being looked at (eg, umbilical artery in 76820)
Nonobstetrical
The next section of ultrasound codes we need to look at is the Pelvis. The pelvis ultrasound codes are further divided between obstetric and non-obstetric. First, let’s look at the obstetric codes. Obstetric ultrasounds are based on whether it is a pregnant uterus ultrasound, or a fetal ultrasound. There are detailed definitions for most of the pregnant uterus ultrasounds in the guidelines. It will be important for you to review these and highlight key sentences, or you may want to highlight the CPT® codes in this set of guidelines, so that it is easy to locate the CPT® being referred to. The fetal ultrasounds are based on what is specifically being evaluated on the fetus. Again, a great place for highlighting or underlining key words.
Non-obstetrical ultrasounds include a transvaginal ultrasound, a sonohysterography, and non-obstetric pelvic ultrasounds. Detailed definitions of these procedures are provided in the guidelines for the nonobstetrical pelvic ultrasound section.

30. Radiologic Guidance Fluoroscopic Computed Tomography (CT)
Magnetic Resonance (MRI)
Other
Following the ultrasound codes is a subsection for radiologic guidance. These codes are selected based on the type of guidance use, whether it is Fluoroscopic, CT, MRI, or stereotactic localization guidance, which is located under “other guidance.”

31. Breast, Mammography Computer aided detection (CAD)
Mammary ductogram or galactogram
Mammography
Screening
Diagnostic
The next subsection of radiology is the Breast imaging and Mammography codes. This subsection of codes is selected based on the imaging device, procedure performed, whether it is screening or diagnostic, and whether it is unilateral or bilateral. Notice the code for a screening mammogram is bilateral. If a mammography is performed for only one breast, it would be for diagnostic reasons, not screening.

32. Bone/Joint Studies Bone age studies Bone length studies Osseous survey
Joint survey
Bone mineral density studies
Bone marrow blood supply
Next, we see bone and joint studies. The most common procedure you hear of in this subsection is a DEXA, or bone mineral density study. DEXA stands for Dual-energy X-ray absorptiometry and is performed to evaluate bone density. Additional tests in this section are performed to evaluate bone age, bone length, etc.

33. Radiation Oncology Consultation: Clinical Management
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
Our next major subsection of radiology is Radiation Oncology. The treatment of cancer with radiation can be used alone, or in a combination with surgery and/or chemotherapy. Radiation oncology is a multidisciplinary medical specialty involving physician, physicists and dosimetrists, nurses, biomedical scientists, computer scientists, radiotherapy technologists, nutritionists, and social workers.
The radiation oncology section is further divided into consultation, treatment planning, Radiation physics and dosimetry, various treatment deliveries, hyperthermia, clinical intracavitary hyperthermia, and clinical brachytherapy. The most important guideline you can highlight or underline here is the last sentence in the first paragraph, “They include normal follow-up care during course of treatment and for three months following its completion.”
The consultation for clinical management by the radiation oncologist is reported by codes from the evaluation and management section of the CPT® coding manual.

34. Clinical Treatment Planning
Interpretation of special testing
Tumor localization
Treatment volume determination
Treatment time/dosage determination
Choice of treatment modality
Determination of number and size of treatment ports
Selection of appropriate treatment devices
Other procedures
Clinical treatment planning is complex and according to your CPT® guidelines involves interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of number and size of treatment ports, selection of appropriate treatment devices, and other procedures. The selection of treatment planning is based on levels of simple, intermediate, and complex. The definitions are listed in your guidelines.

35. Clinical Treatment Planning
Treatment ports – exact place on the body where the radiation will be aimed.
Single port
Simple parallel opposed ports
Converging ports
Tangential ports
Blocks – pieces of lead to cover up normal tissue in the body
To select the appropriate level, you will need to understand a few additional definitions. Ports are the place on the body where the radiation will be aimed. The definitions of treatment planning have references to a single port, simple parallel opposed ports, converging ports, and tangential ports. Most patients have more than one treatment port.
Another reference in treatment planning refers to blocks. Blocks are pieces of lead designed to the patient, to cover up normal tissue so that the radiation focuses on the tumor and not healthy normal tissue.

36. Clinical Treatment Planning
Simulation
Simulation of delivering radiation therapy
Helps determine ports
Can use X-ray, CT, and/or MRI
Simulation level determined by complexity:
Simple
Intermediate
Complex
The second set of codes in Clinical Treatment Planning is for therapeutic radiology simulation. Simulation is where the radiation oncologist uses imaging to plan how to direct the radiation. Typically, the patient will lie very still on a table while the radiation oncologist determines the ports. Sometimes, it is necessary to use a body mold to keep the patient from moving during treatment. Simulation codes are selected based on the definitions in the guidelines for simple, intermediate, complex, and three dimensional.

37. Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services
Beam modifying and shaping blocks
Patient immobilization devices
Beam modifiers (wedges, compensators)
Dosimetrist
Determines the proper radiation dose
Radiation Physicist
Makes sure the machine delivers the right amount of radiation to the correct site in the body
The design and construction of the treatment devices, such as the blocks and patient immobilization devices, are reported with codes from the next radiation oncology subsection of Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services. Also included in this section are services performed by the Dosimetrist who determines the proper radiation does (called dosimetry) and the Radiation Physicist who makes sure the machine delivers the right amount of radiation to the correct site in the body.

38. Treatment Delivery Reports technical component only
Stereotactic Radiation Treatment Delivery
Stereotactic Radiosurgery (SRS)
Stereotactic body radiation therapy
Radiation Treatment Delivery
Neutron Beam Treatment Delivery
Proton Beam Treatment Delivery
TC Only
Your next several sections for Stereotactic Radiation Treatment Delivery, Radiation Treatment Delivery, Neutron Beam Treatment Delivery, and Intensity Modulated Radiation Treatment Delivery (IMRT), represent a technical component only, and would only be reported by the hospital. CPT has included a parenthetical instruction to report with a modifier 26 for the professional component of IMRT. Refer to the Radiation Management and Treatment Table in your CPT Professional Codebook for a complete listing of CPT© codes.

39. Radiation Treatment Management
Includes:
Review of port films
Review of dosimetry, dose delivery, and treatment parameters
Review of patient treatment set-up
Examination of patient for medical evaluation and management
Reported:
Increments of 5
Two treatments per day = 2 fractions per day
3 or 4 fractions beyond a multiple of 5 at end of course
If entire treatment consists of 1 or 2 fractions
The next radiation oncology subsection to discuss is Radiation Treatment Management. Radiation treatment management typically consist of review of port films, review of dosimetry, dose delivery, and treatment parameters, review of patient treatment set-up, and patient visits for response to treatment, coordination of care and treatment, and review of ancillary results. It is reported in units of five fractions or treatment sessions, regardless of the actual time in which the services are furnished. In other words, the patient can come in on Monday, Tuesday, Wednesday of one week and Monday and Tuesday of the next week, and that would be reported as five treatment sessions. Sometimes, you will have patients who might have treatments two times per day. This would be reported as two fractions per day. Radiation treatment management for five treatments is also reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment; one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately.

40. Hyperthermia Use of heat in conjunction with radiation therapy
Investigational
Some policies allow for deep hyperthermia with radiation therapy while considering superficial hyperthermia investigational
Next we see Hyperthermia. Hyperthermia is the use of heat. Hyperthermia in conjunction with radiation therapy is currently under investigation. Some insurance policies will allow the use of only Deep hyperthermia with radiation therapy, but consider it investigational with superficial hyperthermia. Before reporting hyperthermia codes, make sure you read through the guidelines in this section.

41. Brachytherapy
Sealed radioactive material inserted into or around a tumor
Interstitial – inserted into tissue at or near the tumor site
Head and neck
Prostate
Cervix
Ovary
Breast
Perianal
Pelvic
Intracavitary – inserted into the body with an applicator
Uterus
Investigating other areas
The final radiation oncology subsection is clinical brachytherapy. Brachytherapy uses radioactive material sealed in needles, seeds, wires, or catheters. The sealed radioactive material is then placed in or near a tumor. You may also hear this referred to as internal or implant radiation therapy. Interstitial brachytherapy is when the seeds, or other sealed radioactive material, are inserted into tissue at or near the tumor site. Intracavitary brachytherapy is when it is inserted into the body with an applicator.

42. Nuclear Medicine
Diagnostic - Use of small amounts of radioactive material to examine organ function
Thyroid function (endocrine)
Renal (Genitourinary System)
Bone (Musculoskeletal System)
Heart (Cardiovascular system)
Brain (Nervous System)
Therapeutic – uses radioactive material to treat cancer and other medical conditions affecting the thyroid gland
Our last major subsection of Radiology is Nuclear Medicine, which is subdivided into diagnostic and therapeutic. Diagnostic radiotherapy is the use of small amounts of radioactive material to examine organ function and structure. Some common scans performed include thyroid uptake to evaluate thyroid function; Renal imaging to evaluate kidney abnormalities; Bone scans for diagnosing inflammatory processes such as osteomyelitis or for localization of bone tumors; Heart scans such as myocardial perfusion and cardiac blood pool imaging; and Brain scans to investigate cerebrovascular problems. Therapeutic nuclear medicine when radioactive material is used to treat cancer and other medical conditions affecting the thyroid gland.

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