1. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 28 RADIOLOGY

2. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Radiology Radiology: Branch of medicine that uses radiant energy to diagnose and treat patients Specialist in radiology: Radiologist (doctor of medicine)

3. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Radiology Subsections Diagnostic Radiology –Aorta & arteries Diagnostic Ultrasound Radiologic Guidance Breast, Mammography Bone/Joint Studies Radiation Oncology –Clinical Brachytherapy Nuclear Medicine

4. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Terms Fluoroscopy views inside of body, projects onto television screen Live images by which physician can view function and structure of organ –Example: 71034, Chest x-ray with fluoroscopy

5. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Magnetic Resonance Imaging MRI uses magnetic energy to view soft tissue structures –Example: 72148, MRI of lumbar spine canal (Cont’d…)

6. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Tomography or CT Tomography used to view single plane of body –Example: 70450, Tomographic scan of head or brain (Cont’d…)

8. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Biometry Biometry: Application of statistical methods to biological facts –Example: 76516, Use of ultrasound echography in biometry of eye Ultrasound diagnostic non-invasive procedures are performed to determine composition and contours of ocular and orbital structures

10. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Planes of Body Figure: 28.1 Imaginary lines used as points of reference

11. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Position and Projection Position: Way in which patient placed Projection: Path x-ray beam travels

12. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Terminology Radiology uses a wide variety of terms and abbreviations specific to planes, positions, and projections

13. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Component Coding Three component terms –Professional –Technical –Global

14. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Professional Component (-26) Physician portion of service, includes –Supervision of technician –Interpretation of results, including written report From Young AP, Proctor DB: Kinn's The Medical Assistant, ed 10, St. Louis, 2007, Saunders.

15. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Technical Component (-TC) Technologist’s services Equipment, film, and supplies From Long BW, Frank ED, Ehrlich RA: Radiography Essentials for Limited Practice, ed 2, St. Louis, 2006, Saunders.

16. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Component Modifiers If only professional component of radiology service provided append -26 to code (Cont’d…)

18. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Component Modifiers (…Cont’d) If only technical component was provided append -TC to code –-TC: HCPCS modifier used with CPT and HCPCS codes

19. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Global Procedure If both professional and technical components of radiology service provided, use no modifier (Cont’d…)

20. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Global Procedure (…Cont’d) Third-party payers usually reimburse –40% professional component –60% technical component –100% global procedure

22. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Contrast Material Statement “with contrast” implies injection built into code (Cont’d…)

23. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Contrast Material (…Cont’d) Notes indicate codes for components –Example: 75893, venous sampling indicates “(For procedure, use 36500)” Oral or rectal contrast does not qualify for “with contrast”

24. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Overview of Radiology Subsections Diagnostic Radiology Diagnostic Ultrasound Radiologic Guidance Breast, Mammography Bone/Joint Studies Radiation Oncology Nuclear Medicine

25. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 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 number views (Cont’d…)

26. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 Diagnostic Radiology (…Cont’d) Used to: –Diagnose disease –Monitor disease process—progression or remission

27. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Diagnostic Procedures Include X-ray Computerized axial tomography (CAT or CT scan) Magnetic resonance imaging (MRI) Angiography Subdural hematoma CT of renal artery From Mettler FA: Essentials of Radiology, ed 2, Philadelphia, 2005, Saunders. From Walsh PC, editor: Campbell's Urology, ed 8, Philadelphia, 2002, Saunders.

28. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Computerized Axial Tomography X-ray image taken in sections Computer reconstructs and enhances image

29. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 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 contrast material used

30. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Angiography Used to view vessel obstructions Dye injected into vessel (Cont’d…)

31. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 Angiography (…Cont’d) Radiologist uses angiography to diagnose vascular conditions Examples: –Malformations –Strokes –Myocardial infarctions

33. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Remember If fewer than total number of views specified in code provided: –Use -52, Reduced Service

34. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 Diagnostic Ultrasound (…Cont’d) Ultrasound showing a gallstone Figure: 28.14 From Goldman L, Ausiello D, eds: Cecil Medicine, ed 23, Philadelphia, 2008, Saunders.

36. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 Subheadings Subheadings of Diagnostic Ultrasound primarily based on anatomy Example: –Head and Neck –Chest –Pelvis Many notes in subsection directing correct assignment

37. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 Three Locations For Ultrasound Services 76506-76999: Radiology codes for diagnostic ultrasound services 93880-93990: Medicine codes for vascular studies 93303-93352: Medicine codes for echocardiography

38. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 Interventional Radiologist Combination radiologist and surgeon Provides total procedure for cystography with contrast –Report 74430, X-ray portion and –51600 for injection procedure, –Plus code for supply of contrast material (e.g., 99070 or HCPCS code)

39. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 Ultrasound Modes and Scans A-mode or A-scan technology— one-dimensional M-mode—one-dimensional measurement procedure with movement of trace to allow amplitude and velocity of moving echo- producing structures B-scan technology—two-dimensional Real-time scan A & B scan may be performed together (medical necessity documented)

40. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 A-Mode A = Amplitude Technique used to map structure outline Displays one-dimensional image

41. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 M-Mode M = Motion Technique used to display movement of structure Displays one-dimensional image

42. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 42 B-Scan B = Brightness Technique used to display movement of tissues and organs Known as gray scale ultrasound Displays two-dimensional image

43. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43 Real-Time Scan Technique used to display both structure and motion with time of organ and tissues Displays two-dimensional image

44. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 44 Extent of Study Codes often divided on extent of study Example: Extent of scan as follows (Cont’d…)

45. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 45 Extent of Study (…Cont’d) Complete: Scans entire body Limited: Scans part of body, i.e., one organ Follow-up/repeat: Limited study of part of body that was scanned previously

46. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 46 Radiologic Guidance, Breast, Mammography, Bone/Joint Studies, and Radiation Oncology Radiologic Guidance (77001-77032) –Fluoroscopic, computed tomography, magnetic resonance guidance, and other Breast, Mammography (77051-77059) –Such as screening, and computer-aided detection Bone/Joint Studies (77071-77084) –Such as bone density and joint survey Radiation Oncology (77261-77799) –Therapeutic use of radiation –Codes for both professional and technical services –Subheading divided based on treatment

47. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 47 Radiation Oncology Initial consultation, prior to decision to treat, reported with E/M Consultation code –Outpatient: 99241-99245 –Inpatient: 99251-99255 Follow consultation criteria: Document who and why

48. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 48 Clinical Treatment Planning— Professional Component Includes: –Interpretation of special testing –Tumor localization –Determination of treatment volume (Cont’d…)

49. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 49 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. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 50 Clinical Treatment Planning (…Cont’d) Clinical Treatment Planning consists of –Three types of treatment plans –For all patients requiring radiation therapy

51. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 51 Levels of Planning (77261-77263, 77299) Simple: One treatment area, one port or one set of parallel ports Intermediate: Three or more ports, two separate treatment areas, multiple blocking (Cont’d…)

52. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 52 Levels of Planning (…Cont’d) Complex: Complex blocking, custom shielding blocks, tangential ports, special wedges, or compensators, three or more treatment areas, special beams Unlisted procedure (77299)

53. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 53 Simulation (77280-77295) Determines placement of treatment areas/ports for radiation treatment Does not include administration of radiation (Cont’d…)

54. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 54 Four Levels of Simulation (…Cont’d) Simple: One treatment area with one port or pair of ports Intermediate: Three or more ports, two separate treatment areas, multiple blocking Complex: Tangential ports, three or more treatment areas, complex blocking 3D: Computer generated three-dimensional image of tumor

55. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 55 Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services (77300-77370, 77399) Decision-making services of physicians –Treatment types –Dose calculation and placement (dosimetry) –Development of treatment device Stereotactic Radiation Treatment Delivery (77371-77373) –Pay close attention to notes Delivers large dose to specific tumor site

56. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 56 Radiation Treatment Delivery (77401-77423, 77520-77525) Radiation (77401-77421) Neutron Beam (77422, 77423) Proton Beam (77520-77525) Technical component of actual delivery of radiation –MeV (electrons) –Neutrons –Protons

57. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 57 Information Needed to Code Radiation Treatment Delivery Amount of radiation delivered Type of radiation—electron (most common), neutron, or proton (Cont’d…)

58. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 58 Information Needed to Code Radiation Treatment Delivery (…Cont’d) Number of –Areas treated (single, two, three or more) –Ports involved (single, three or more, tangential) –Blocks used (none, multiple, custom)

59. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 59 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 additional fraction

60. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 60 Clinical Brachytherapy (77750– 77799) Placement of radioactive material into or around site of tumor: –Intracavitary (within body cavity) –Interstitial (within tissues) (Cont’d…) From Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG: Clinical Oncology, ed 3, Philadelphia, 2004, Churchill Livingstone.

61. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 61 Source (…Cont’d) Radioactive element delivers radiation dose over time –Examples: Seeds, ribbons, or capsules –Ribbons: Seeds embedded on tape Tape cut to desired length controls amount of radiation and inserted into tissue (Cont’d…)

62. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 62 Clinical Brachytherapy Codes Divided Based On (…Cont’d) Number of sources applied: –Simple: 1-4 –Intermediate: 5-10 –Complex: 11+

63. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 63 Nuclear Medicine Placement of radioactive material into body and measurement of emissions Used both for diagnosis and treatment –Example: Stress test (Cont’d…)

64. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 64 Nuclear Medicine (…Cont’d) Codes divided primarily on organ system –Exception: “Therapeutic,” for radiopharmaceutical therapies

65. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 65 Positron Emission Tomography (PET) 78811-78816 Based on location (such as, skull base or chest) Non-invasive imaging procedure that assesses perfusion and level of metabolic activity in various organ systems PET lesions in the liver From Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG: Clinical Oncology, ed 3, Philadelphia, 2004, Churchill Livingstone.

66. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 66 Conclusion CHAPTER 28 RADIOLOGY