1. CPT: Radiology, Pathology and Laboratory, and Medicine Codes
PART THREE
INTRODUCTION TO CPT
Chapter 9
CPT: Radiology, Pathology and Laboratory, and Medicine Codes
McGraw-Hill/Irwin
Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.

2. 9-2
LEARNING OUTCOMES
After studying this chapter, you should be able to:
Discuss the organization, key guidelines, and common modifiers for the Radiology section of CPT.
Discuss the importance of the number of views taken in radiology coding.
Explain the difference between the professional and technical components of a procedure.
Describe the use of contrast material in assigning radiology codes.
Distinguish between screening and diagnostic services.
Describe the organization, key guidelines, and common modifiers for the Pathology and Laboratory section of CPT.
Recognize common laboratory panels and their associated codes.
Describe the organization, key guidelines, and common modifiers for the Medicine section of CPT.
Describe the correct coding of immunizations.
Assign CPT radiology, pathology and laboratory, and medicine codes with appropriate modifiers based on procedural statements.

3. KEY TERMS Administration Analyte Ancillary services Assay Automated
9-3
KEY TERMS
Administration
Analyte
Ancillary services
Assay
Automated
Biofeedback
Cardiac catheterization
Charge capture
Charge description master (CDM)
CLIA-waived test
Clinical Laboratory Improvement Amendment (CLIA)
Complete blood count (CBC)
Complete lab test
Computerized axial tomography scan (CT or CAT scan)
Continuous positive airway pressure (CPAP)
Contrast material (media)
Diagnostic procedure
Echocardiography
Electrocardiogram (ECG/EKG)
Encounter form
Fluoroscopy

4. KEY TERMS Hemodialysis Immunotherapy Magnetic resonance imaging (MIR)
9-4
KEY TERMS
Hemodialysis
Immunotherapy
Magnetic resonance imaging (MIR)
Mammography
Manual
Modality
Nuclear medicine
Panel
Peritoneal dialysis
Positron emission tomography (PET)
Professional component (PC)
Radiation oncology
Radiologic examination
Radiology
Radiology report
Red blood cell count (RBC)
Screening procedure
Single proton emission computerized tomography (SPECT)
Spirometry
Technical component (TC)
Ultrasound
White blood cell (WBC) count

5. 9-5
ANCILLARY SERVICES
Support the diagnosis and treatment of a disease or injury.
Include work such as: laboratory tests, radiological studies, pathology studies, physical therapy and speech therapy.
These services are provided to the patient at the request of a physician.
Some are performed in the hospital and others are done in physician offices, clinics or another facility.

6. 9-6
RADIOLOGY
CPT codes in this section concentrate on medical imaging to prevent, diagnose, and treat diseases or injuries.
Radiologists diagnose disease by obtaining and interpreting medical images.
Radiologist also treat a number of diseases by radiation.
Codes in this section can be used by any physician of any medical specialty to report radiological services performed by the physician or under the physician’s supervision.

7. RADIOLOGY SECTION Has 7 subsections
9-7
RADIOLOGY SECTION
Has 7 subsections
Diagnostic Radiology – 76499
Diagnostic Ultrasound – 76999
Radiologic Guidance – 77032
Breast, Mammography – 77059
Bone/Joint Studies – 77084
Radiation Oncology – 77999
Nuclear Medicine – 79999
Organized by the method or type of radiology and the purpose of the service
Subdivided by anatomical site & type of service

8. 9-8
RADIOLOGY GUIDELINES
The physician ordering the radiology service needs to submit an order giving the reason for the examination.
If contrast materials are used, be sure to check for a bundled code or need for two codes.
A complete radiological service includes the use of equipment/supplies and the physician’s work. Modifiers are typically used to show which component was done, unless the physician did both.
Technical component (TC) – the staff, technologists work, equipment, supplies or preinjection/postinjection services; typically the facility charge
Professional component (PC) – reading and interpreting the radiological test and providing a written report with findings; typically reported by the physician

9. RADIOLOGY MODIFIERS -22 – unusual (increased) procedural service
9-9
RADIOLOGY MODIFIERS
-22 – unusual (increased) procedural service
-26 – professional component
-32 – mandated services
-51 – multiple procedures
-52 – reduced services
-58 – staged or related procedure or service by the same physician during the postop period
-59 – distinct procedural service
-62 – two surgeons-63 – procedure performed on infants less than 4 kg
-66 – surgical team
-76 – repeat procedure by same physician
-77 – repeat procedure by another physician
-78 – return to the operating room for a related procedure during the postoperative period
-79 – unrelated procedure or service by the same physician during the postoperative period
-80 – assistant surgeon
-99 – multiple modifiers
-LT, -RT, -TA to -T9, -FA to –F9, -LC, -LD, -RC – Anatomical modifiers

10. DIAGNOSTIC RADIOLOGY Arranged by anatomical site and then modality
9-10
DIAGNOSTIC RADIOLOGY
Arranged by anatomical site and then modality
Common procedures:
Radiologic Examination
Computerized Axial Tomography (CT or CAT scan)
Magnetic Resonance Imaging (MRI)
Fluoroscopy
Diagnostic Ultrasound
Radiologic Guidance
Mammography
Bone/Joint Studies
Radiation Oncology
Nuclear Medicine

11. STEPS IN ASSIGNING RADIOLOGY CODES
9-11
STEPS IN ASSIGNING RADIOLOGY CODES
Review the complete medical documentation and identify the type of service performed.
Locate the body site being viewed.
Locate the terms in the CPT index.
Read the code descriptors to select codes based on radiology terminology.
Consider assignment of modifiers.

12. PATHOLOGY AND LABORATORY
9-12
PATHOLOGY AND LABORATORY
Contains a broad range of codes from routine tests performed in a physician office to highly sophisticated labs
Laboratory services are done to assess patient specimens
Pathology services are done to identify diseases by studying cells and tissues under a microscope
Most codes are for the technical component only

13. PATHOLOGY AND LABORATORY GUIDELINES
9-13
PATHOLOGY AND LABORATORY GUIDELINES
Guidelines and notes are located before the codes.
Assign as many codes as necessary to capture all services performed.
Unlisted codes are available and should be assigned only after checking Category III or HCPCS level II codes.
Every laboratory test must be ordered by a physician, physician’s assistant or registered nurse practitioner.

14. PATHOLOGY AND LABORATORY SUBSECTIONS
9-14
PATHOLOGY AND LABORATORY SUBSECTIONS
Organ or disease panels
Drug testing
Therapeutic drug assays
Evocative/suppression testing
Consultations (clinical Pathology)
Urinalysis
Chemistry
Hematology and coagulation
Immunology
Transfusion Medicine
Microbiology
Anatomic Pathology
Cytopathology
Cytogenetic Studies
Surgical Pathology
Transcutaneous Procedures
Other Procedures
Reproductive Medicine Procedures

15. COMPLETE LABORATORY CODES
9-15
COMPLETE LABORATORY CODES
Includes ordering the procedure or test, obtaining the sample or specimen, handling the specimen, performing the actual procedure or test, and analyzing and interpreting the results
Blood can be collected via a vein, capillary stick or other device.
All lab work is regulated by Clinical Laboratory Improvement Amendments (CLIA) rules.

16. PATHOLOGY AND LABORATORY MODIFIERS
9-16
PATHOLOGY AND LABORATORY MODIFIERS
-22 – unusual (increased) procedural services
-26 – professional component
-32 – mandated services
-52 – reduced services
-53 – discounted procedure
-59 – distinct procedural service
-90 – reference (outside) laboratory
-91 – Repeat clinical diagnostic lab test

17. ORGAN AND DISEASE-ORIENTED PANELS
9-17
ORGAN AND DISEASE-ORIENTED PANELS
A panel is a group of lab tests commonly performed together to diagnose organ dysfunction or to monitor a disease
Common Panels:
Basic metabolic
General Health
Electrolyte
Comprehensive metabolic 80053
Obstetric
Lipid
Renal function
Acute Hepatitis
Hepatic function

18. LABORATORY CODES Common procedures: Drug testing
9-18
LABORATORY CODES
Common procedures:
Drug testing
Therapeutic drug assays
Evocative/suppression testing
Urinalysis
Chemistry
Hematology and coagulation
Immunology
Transfusion medicine
Microbiology
Cytopathology
Pathology consultations
Surgical pathology

19. STEPS IN ASSIGNING LABORATORY CODES
9-19
STEPS IN ASSIGNING LABORATORY CODES
Based on the documentation locate the services in the CPT index.
Read all code descriptions from the code ranges provided.
Select code based on whether the procedure was quantitative or qualitative.
Consider modifier assignment.

20. 9-20
MEDICINE SECTION
Includes codes for procedures that are primarily evaluative, diagnostic and/or therapeutic.
Codes for non-invasive or minimally invasive procedures
Most procedures are typically performed in the physician office.
Many codes are driven by time, quantity, age and professional component service.
Located directly before the Category II and Category III codes
Subsections are arranged by specialty areas or type of service

21. 9-21
MEDICINE GUIDELINES
When coding multiple procedures, watch for unbundling, add-on codes, and separate procedures.
Many times more than one code is required.
E/M codes can only be assigned in addition if this was a significant, separate E/M service.

22. MEDICINE SUBSECTIONS Immune Globulins 90281-90399
9-22
MEDICINE SUBSECTIONS
Immune Globulins
Immunization Administration for Vaccines/ Toxoids
Vaccines, Toxoids
Hydration, Therapeutic, Prophylactic, & Diagnostic Injections & Infusions
Psychiatry
Biofeedback
Dialysis
Gastroenterology
Ophthalmology
Special Otorhinolarngologic services
Cardiovascular
Noninvasive Vascular Diagnostic Studies
Pulmonary
Allergy and Clinical Immunology
Endocrinology
Neurology and Neuromuscular Procedures

23. 9-23
MEDICINE SUBSECTIONS
Medical Genetics and Genetic Counseling Services 96040
Central Nervous System Tests
Health and Behavior Assessment
Chemotherapy Administration
Photodynamic Therapy
Special Dermatological Procedures
Physical Medicine and Rehabilitation
Medical Nutrition Therapy
Acupuncture
Osteopathic Manipulative Treatment
Chiropractic Manipulative Treatment
Education and Training for Patient Self Management
Special Services, Procedures and reports
Qualifying Circumstances for Anesthesia
Moderate (Conscious) Sedation
Home Health Procedures/Services

24. MEDICINE MODIFIERS -22 – unusual (increased) procedural service
9-24
MEDICINE MODIFIERS
-22 – unusual (increased) procedural service
-26 – professional component
-51 – multiple procedures
-52 – reduced services
-53 – discontinued procedure
-55 – postoperative management
-56 – preoperative management
-57 – decision for surgery
-58 – staged or related procedure or service by the same physician during the postop period
-59 – distinct procedural service
-76 – repeat procedure by same physician
-77 – repeat procedure by another physician
-78 – return to the operating room for a related procedure during the postoperative period
-79 – unrelated procedure or service by the same physician during the postoperative period
-LC, -LD, -RC – Coronary artery modifiers
-LT, -RT, -TA to -T9, -FA to –F9, - Anatomical modifiers

25. ASSIGNING MEDICINE CODES
9-25
ASSIGNING MEDICINE CODES
Review the documentation and determine the type of service provided.
Locate main terms in the CPT index.
Determine if drugs were given.
Check subterms and read descriptors thoroughly.
Verify that the code description matches the services documented.
Assign codes for all significant services and consider modifiers, if appropriate.