Chapter 17: CPT® Section Radiology Workbook Answers and Rationale.
Case 1
Location: Imaging center, radiologist employed. |1|
Study: Femur AP and Lateral |2|
Reason: Left leg pain
Left Femur:
Comparison: There are no prior studies for comparison.
Findings: There is no fracture or dislocation of the left femur. The femoral head is concentrically seated within the acetabulum
without deformity of the femoral head.
Impression: Normal |3| views of the left femur.
|1| Radiologist is employed by the imaging center; the imaging center should report the global component.
|2| 2 views taken.
|3| Findings are normal, the reason for the study is used for the diagnosis.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 73552-LT
ICD-10-CM code: M79.605
Rationale:
CPT® Code: In the CPT® Index look for X-ray/Femur referring you to 73551, 73552. 73552 is supported by the AP (anteriorposterior)
and lateral views in the report. The X-ray was taken at an imaging center, which employs the radiologists. The
global procedure is reported with no modifiers (26 or TC). Modifier LT can be appended to indicate the left femur was X-rayed.
ICD-10-CM Code: Look in the ICD-10-CM Alphabetic Index for Pain(s)/leg – see Pain, limb, lower. Look for Pain/limb/lower
referring you to M79.60-. In the Tabular List, 6th character 5 is reported for the left leg. Verify code selection in the Tabular
List.
Case 2
Location: Regional Hospital |1|
MRI of the lumbar spine
History: Low back pain. |2|
Technique: On a 1.5 Tesla magnet multiple sagittal and axial |3| images were performed through the lumbar spine |4| using variable
pulse sequences.
Findings: There is normal lumbar alignment. The conus is in normal position at the thoracolumbar junction. No suspect bone
marrow lesions are present. There is mild anterior wedging of the L3 vertebral body. I am uncertain whether this is an acute or
chronic finding.
At the T12-L1 level, there is a small posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis.
At the L1-L2 level, there is no disc bulge or protrusion. There is no central canal or neural foraminal stenosis.
At the L2-L3 level, there is moderate loss of disc height. There is 106s of T2 signal. There is a focal area of increased T1 signal
involving the L2-L3 disc. This could be related to disc calcification or possibly blood product. There is a small posterior disc bulge.
There is no central canal stenosis. There is no neural foraminal stenosis.
At the L3-L4 level, there is a minimal posterior disc bulge. There is no central canal stenosis. There is no neural foraminal stenosis.
At the L4-L5 level, there is mild loss of disc height and loss of T2 disc signal. There is a moderate size right paracentral disc
protrusion impinging the anterior aspect of the thecal sac. There is no central canal stenosis. There is no neural foraminal stenosis.
At the L5-S1 level, there is no disc bulge or disc protrusion. There is no central or neural foraminal stenosis.
Impression: Mild anterior wedging of the L3 vertebral body. |5| It is uncertain whether this is acute or chronic finding. There is
increased T1 signal involving the L2-L3 disc which could be related to calcification or possible hemorrhage although this is felt to be
less likely.
Moderate size right paracentral disc protrusion at L4-L5. |6| Multilevel degenerative disc disease. |7|
|1| The hospital will report the technical component. Only the professional component should be reported.
|2| Reason for the MRI, also known as Lumbago.
|3| Sagittal and axial images were taken.
|4| Location—lumbar spine.
|5| Wedging of vertebrae is considered Osteoporosis.
|6| Disc protrusion is coded as intervertebral disc displacement and is in the lumbar region.
|7| Degenerative Disc Disease covers more than one level in the lumbar spine.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 72148-26
ICD-10-CM codes: M48.56XA, M51.26, M51.36
Rationale:
CPT® Code: MRIs can be performed with or without contrast. This record shows no indication of contrast material being
used. To find the code, look in the CPT® Index for Magnetic Resonance Imaging (MRI)/Diagnostic/Spine/Lumbar referring
you to code range 72148-72158. The code is determined based on whether or not contrast is used. 72148 is an MRI of the
lumbar spinal canal and contents, without contrast material. Modifier 26 is used to report the professional component only.
The technical component is reported by the hospital.
ICD-10-CM codes: In the ICD-10-CM Alphabetic Index look for Wedge-shaped or wedging vertebra directing you to – see
Collapse, vertebra NEC. Look for Collapse/vertebra/lumbar region referring you to M48.56-. Turn to the Tabular List to
complete the code. The complete code is M48.56XA. Next, look for Protrusion/intervertebral disc – see Displacement/
intervertebral disc. Look for Displacement/intervertebral disc NEC/lumbar region referring you to M51.26; because the disc
protrusion is at L4-L5. Degenerative disc is found under Degeneration, degenerative/ intervertebral disc NOS/lumbar region
referring you to M51.36. Verify code selection in the Tabular List.
Case 3
Location: Imaging center; radiologist employed. |1|
Study: Mammogram bilateral screening, |2| all views, producing direct digital image.
Reason: Screen
Bilateral digital mammography with computer-aided detection (CAD). |3|
No previous mammograms are available for comparison.
Clinical History: The patient has a positive family history of breast cancer. |4|
Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.
Findings: Residual fibroglandular breast parenchymal tissue is identified bilaterally. No dominant spiculated mass or suspicious
area of clustered pleomorphic microcalcifications are apparent. Skin and nipples are seen to be normal. The axilla is unremarkable.
Impression: BIRADS 1—Negative |5|
|1| Radiologist is employed by the imaging center; the imaging center should report the global component.
|2| Screening bilateral mammogram.
|3| Use of CAD.
|4| Family history of breast CA.
|5| Negative screening.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 77067
ICD-10-CM codes: Z12.31, Z80.3
Rationale:
CPT® codes: Look in the CPT® Index for Mammography/Screening. Report code 77067. Because the services are performed
by an imaging center, and the radiologists are employed, the global service is reported (no modifiers 26 or TC).
ICD-10-CM codes: This is a screening mammogram. Look in the ICD-10-CM Alphabetic Index for Mammogram
(examination)/routine referring you to Z12.31. A secondary diagnosis of family history of breast cancer is also reported. Look
in the Alphabetic Index for History/family (of)/malignant neoplasm (of)/breast referring you to Z80.3. Verify code selection
in the Tabular List.
Case 4
Location: Independent Diagnostic Testing Facility, radiologist employed by the facility. |1|
CT brain/head w/wo contrast exam: CT head, without and with contrast August 5, 20XX
Comparison: None available.
History: Non-small-cell lung cancer. |2|
Technique: Axial images of the calvarium without and with |3| 125 cc Omnipaque-300 intravenous contrast. |4|
Findings: The calvarium is intact. Imaged upper portions of the maxillary antra show minimal mucosal thickening. The sphenoid
ethmoid and frontal sinuses are clear bilaterally. No hydrocephalus, mass effect, brain shift, abnormal extra-axial fluid collection
or mass. Calcification left basal ganglia without mass effect, nonspecific, likely benign. Abnormal but nonspecific decreased density
in the periventricular and subcortical white matter of the cerebral hemispheres bilaterally without mass effect or enhancement,
most consistent with remote microvascular ischemic change present to mild degree. Bilateral intracavernous carotid and
vertebral arteriosclerotic calcification. Probable anterior communicating artery aneurysm 6 x 5 mm. Recommend intracranial CT
angiography to further characterize.
Conclusion: 1. No finding suggestive of metastatic disease. 2. Probable |5| 6 x 5 mm anterior communicating artery aneurysm.
Recommend intracranial CT angiography to further characterize. 3. Cerebrovascular arteriosclerosis. |6| 4. Nonspecific cerebral
white matter lesions |7| most consistent with remote microvascular ischemic change. 5. Calcification left basal ganglia, |8| likely
benign; however, recommend continued imaging follow up.
|1| Radiologist is employed by the facility, the IDTF will bill for global component.
|2| Patient has non-small-cell lung cancer, not specified to location in lung.
|3| CT performed without and with contrast.
|4| Contrast was intravenous.
|5| Aneurysm is probable and would not be coded.
|6| Additional diagnosis of cerebrovascular arteriosclerosis.
|7| Additional diagnosis of cerebral lesions.
|8| Additional diagnosis of calcification left basal ganglia.
What are the CPT® and ICD-10-CM codes reported?
CPT® code: 70470
ICD-10-CM codes: C34.90, I67.2, G93.9, G23.8
Rationale:
CPT® code: In the CPT® Index, look for CT Scan/without and with Contrast/Brain referring you to 70470 and 70496. 70496
reports a CTA (Computed Tomography Angiography). This service is reported with 70470.
ICD-10-CM codes: ICD-10-CM coding guidelines IV.L indicates: For outpatient encounters for diagnostic tests that have
been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive
diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.
In the ICD-10-CM Alphabetic Index, look for Cancer-see also Neoplasm, by site, malignant. In the Table of Neoplasms look for,
Neoplasm, neoplastic/lung/Malignant Primary column which directs you to subcategory code C34.9-. Turn to the Tabular
List to complete the code. The complete code is C34.90. Further location within the lung is unknown. For the cerebrovascular
arteriosclerosis, look in the Alphabetic Index for Arteriosclerosis/cerebrovascular referring you to I67.2. Cerebral lesions are
found by looking for Lesion(s)/brain referring you to G93.9. Basal ganglia are located in the cerebral cortex. Next, look for
Calcification/basal ganglia referring you to G23.8. Verify codes in the Tabular List.
Case 5
Location: Regional hospital. |1|
Study: Ultrasound Urinary Tract
Indications: Status ureteral reimplantation |2| to evaluate for continued vesicoureteral reflux
Left Kidney: |3| Length: 7.0 cm
Prior length: 7.4 cm
Parenchyma: Cortical scarring.
Pelvic dilatation: Normal
Calyceal dilatation: Normal
Hydronephrosis grade: Normal
Right Kidney: Length: 6.6 cm,
Prior length: 6.4 cm,
Parenchyma: Cortical scarring.
Pelvic dilatation: Normal
Calyceal dilatation: Normal
Hydronephrosis grade: Normal
Interval hydronephrosis change: None
Ureters: |4| Normal.
Bladder: |5| Almost empty and difficult to evaluate.
Impression:
1. Interval right renal enlargement without hydronephrosis. |6|
2. Stable asymmetric small left renal size |7| likely to represent diffuse cortical scarring.
|1| Provided at the hospital, the radiologist will report the professional component.
|2| The surgical procedure has been performed. The ultrasound is being performed after a surgical procedure for evaluation of
continued reflux.
|3| Kidney evaluated.
|4| Ureters evaluated.
|5| Bladder evaluated.
|6| Diagnosis—right renal growth.
|7| Secondary diagnosis—small left renal size.
What are the CPT® and ICD-10-CM codes reported for this service?
CPT® code: 76770-26
ICD-10-CM codes: Z48.816, N13.70, N28.81, N27.0
Rationale:
CPT® code: In the CPT® Index, look for Ultrasound/Bladder referring you to 51798. Look for Ultrasound/Kidney referring you
to code range 76770-76776. 51798 is for measurement of post-voiding residual urine which is not appropriate. 76770-76775
are for ultrasound, retroperitoneal, complete or limited. The examination of the complete urinary tract (kidney, ureters,
and urinary bladder) indicate a complete retroperitoneal ultrasound exam and is reported with 76770. Modifier 26 is used
to report the professional component only because this was performed at a hospital. The hospital will report the technical
component.
ICD-10-CM codes: The patient had a surgical ureteral implantation for vesicoureteral reflux. According to the ICD-10-CM
guidelines I.C.21.c.7, Aftercare visit codes cover situations when the initial treatment of a disease or injury has been
performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences
of the disease. To find the diagnosis code, look in the ICD-10-CM Alphabetic Index for Aftercare/following surgery (for)
(on)/genitourinary system referring you to Z48.816. Aftercare codes are listed as the first-listed diagnosis. The secondary
diagnosis is vesicoureteral reflux. Look for Reflux/vesicoureteral N13.70. For the next diagnosis, right renal enlargement,
look for Enlargement – see also Hypertrophy. Look for hypertrophy, hypertrophic/kidney (compensatory) referring you to
N28.81. Look for Small/kidney (unknown cause)/unilateral referring you to code N27.0. Verify code selection in the Tabular
List.
Case 6
Location: Regional Hospital |1|
Fluoro Hysterosalpingogram
Examination: Hysterosalpingogram |2| (procedure performed by radiologist) |3|
Indication: Infertility |4| for 15 years. Patient had one child 15 years ago. Last menstrual period was 1/13/20XX.
No history of pelvic infection or surgery.
Comparison: None
Procedure: The examination and anticipated discomfort was discussed with the patient. A plastic vaginal speculum was
introduced with the patient’s legs in the stirrups following preliminary vaginal examination and lubrication. The posterior vaginal
fornix and outer cervical os were prepped with a cleansing solution. A 5-F hysterosalpingogram catheter |5| was used. The catheter
balloon was inflated in the lower uterine segment. Fluoroscopic and radiographic assessments were done. |6|
The patient tolerated the procedure well.
Findings: Contrast |7| was administered through the catheter and multiple images were taken. There is a possible abnormal contour
to the right cornua with patchy contrast opacification which may represent intramural contrast with intravasation.
No definite spillage of contrast from either fallopian tube was identified
Impression:
1. Possible right cornual contour abnormality manifested by focal extravasation and minimal intravasation of undetermined
etiology. Recommend endovaginal ultrasound for further evaluation.
2. No contrast filling of either tubes and no spill into pelvic peritoneal space.
|1| The location is the hospital, so the radiologist will report the professional component only.
|2| Hysterosalpingogram is procedure performed.
|3| The procedure was performed by the radiologist.
|4| Reason for test is infertility.
|5| Catheter inserted.
|6| Fluoroscopy and X-rays were utilized.
|7| Contrast used.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 58340, 74740-26
ICD-10-CM code: N97.9
Rationale:
CPT® codes: In the CPT® Index look for Hysterosalpingography referring you to the radiology code 74740. Next, look for
Hysterosalpingography/Injection Procedure referring you to 58340. 58340 reports the catheterization and injection of
contrast material for a hysterosalpingography. In reading the parenthetical instructions, you are instructed to use 74740 for
the supervision and interpretation of the hysterosalpingography. A Modifier 26 is used to report the professional component
only. Do not report 58345 because the catheter was not placed in the fallopian tubes.
ICD-10-CM code: The procedure was performed for infertility. In the ICD-10-CM Alphabetic Index look for Infertility/female
and referring you to N97.9. On exam, the radiologist found extravasation and minimal intravasation of undetermined
etiology, but it is not noted this is the cause of infertility; therefore, not reported. Verify code selection in the Tabular List.
Case 7
Location: Regional Hospital |1|
CT thorax w/contrast, CT abdomen w/contrast, CT pelvis w/contrast, low osmolar contrast |2|
Exam: CT chest with contrast; CT abdomen with contrast; CT pelvis with contrast August 5, 20XX.
Comparison: CT chest Regional Hospital 7/8/20XX.
History: Non-small-cell lung cancer. |3|
Technique: Axial images of the chest, abdomen pelvis with oral and 125 cc Omnipaque-300 intravenous contrast. |4|
Findings: Chest CT |5| shows left upper |6| lobe and pulmonary mass which appear centrally necrotic abutting the posterior pleural
surface and mediastinum without definitive invasion, 83 x 64 mm, prior 76 x 56 mm, image 15. Stable lingular and left basilar,
right middle lobe and right lower lobe superior segment pleural-parenchymal opacity suggesting scarring. New mild subsegmental
infiltrate left upper lobe. No pneumothorax or pleural fluid. No thoracic adenopathy. Heart size normal, no pericardial effusion. Left
coronary arteriosclerotic calcification present. No osseous neoplasm. Abdomen CT |7| shows normal liver, gallbladder, biliary ducts,
pancreas, spleen, adrenal glands and kidneys. Stomach and duodenum within normal limits. Aortoiliac arterial sclerosis without
aneurysm. No retroperitoneal adenopathy. Pelvis |8| CT shows no mass, adenopathy or ascites. No bowel obstruction. No hernia. No
osseous neoplasm. Lumbar spine degenerative change present. Left-sided muscle atrophy and brace noted.
Conclusion:
1. Increasing size left upper lobe pulmonary mass |9| with central cavitation suggested.
2. No thoracic adenopathy or distant metastatic disease demonstrated.
3. Coronary arteriosclerosis. |10|
|1| Performed at the hospital, the radiologist will only code for the professional component.
|2| Three separate CT scan performed:
Thorax (chest)
Abdomen
Pelvis
|3| Pt has non-small cell lung CA.
|4| Contrast used.
|5| Chest CT findings.
|6| Mass is in the left upper lobe.
|7| Abdomen CT findings.
|8| Pelvis CT findings.
|9| The mass is part of the lung CA.
|10| Secondary diagnosis of coronary arteriosclerosis.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 74177-26, 71260-26
ICD-10-CM codes: C34.12, I25.10
Rationale:
CPT® Codes: In the CPT® Index, look for CT Scan/with Contrast/Abdomen and CT Scan/with Contrast/Pelvis. Code 74177 is a
combination code reported for the abdomen and pelvis. Next, look for CT Scan/with Contrast/Thorax referring you to 72160.
Modifier 26 is appended to show the professional component only; the hospital will report the technical component.
ICD-10-CM codes: The patient has non-small cell lung cancer. The mass/tumor is specified in the report as being in the
left upper lobe. In the ICD-10-CM Alphabetic Index, look for Cancer – see also Neoplasm, by site, malignant. In the Table
of Neoplasms, look for Neoplasm, neoplastic/lung/upper lobe/Malignant Primary referring you to subcategory C34.1-. In
the Tabular List, 5th character 2 is reported for the left lung. The radiologist also notes a secondary diagnosis of coronary
arteriosclerosis. Look in the Alphabetic Index for Arteriosclerosis/coronary (artery) or Disease, diseased/artery/coronary
referring you to I25.10. Verify code selection in the Tabular List.
Case 8
Location: Regional Hospital
Exam:
Renal and bladder ultrasound dated 10/01/20XX
Renal artery |1| Doppler evaluation dated 10/01/20XX
Comparison: Renal MRA dated 04/01/20XX
History: 80-year-old with renal artery stenosis. Diagnostic ultrasound of the kidneys was ordered to see if there was kidney damage
due to the renal stenosis or other kidney issues. This was followed after review with a renal Doppler study.
Findings: Multiple grayscale sonographic and color Doppler images of the kidneys and renal vasculature were submitted for
interpretation. |2|
The right kidney measures 10.1 cm without evidence of pelvic caliectasis. |3|
There is a small 8 mm cyst noted within the lower pole of the right kidney. There is relatively normal internal architecture and
echogenicity. The left kidney measures 10.4 cm with no evidence of pelvicaliectasis. There are at least 3 renal cysts identified, the
largest measuring 2 cm in diameter. There is normal internal architecture and echogenicity. The bladder is distended with urine and
appears within normal limits. |3|
The aorta demonstrates peak systolic velocity of 1.07 m/sec.
The right renal artery origin demonstrates peak systolic velocity of 3.0 m/sec with a resistive index of 0.92. The midportion of the
right renal artery demonstrates a peak systolic velocity of 1.1 m/sec with resistive index of 0.8. The right renal hilum has a peak
systolic velocity of 0.64 m/sec with resistive index of 0.85. The inferior pole has a systolic velocity of 0.16 m/sec with resistive index
of 0.54. The midpole has a systolic velocity of 0.18 m/sec and resistive index of 0.70. |4|
The superior pole has a velocity peak of 0.22 m/sec with a resistive index of 0.77.
The left renal artery origin demonstrates a peak systolic velocity of 2.0 m/sec with a resistive index of 0.87. The mid portion of the
left renal artery demonstrates a peak velocity at 0.42 m/sec and a resistive index of 0.80. The left renal hilum has a peak systolic
velocity of 0.47 m/sec and a resistive index of 0.82. The inferior pole has a systolic velocity of 0 16 m/sec and a resistive index of 0.67.
The midpole has a systolic velocity of 0.17 m/sec and a resistive index of 0.63. |5|
The superior pole has a velocity peak of 0.13 m/sec with a resistive index of 0.69. |6|
Impression: Renal artery Doppler study:
1. Moderate stenosis of the right renal artery origin. |6|
2. Mild to moderate left renal artery origin stenosis.
Renal and bladder ultrasound:
1. Bilateral probable |7| renal cysts.
2. Normal appearing bladder
|1| Renal artery is a “visceral artery.”
|2| Indicates this provider only provided an interpretation supporting the use of modifier 26.
|3| Right and left renal and bladder ultrasound.
|4| Right renal artery Doppler evaluation.
|5| Left renal artery Doppler evaluation.
|6| Stenosis of the right and left renal artery will be used as the diagnosis.
|7| Probable diagnosis should not be coded.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 93976-26, 76770-26-59
ICD-10-CM code: I70.1
Rationale:
CPT® codes: The radiologist interpreted a renal artery Doppler study. The renal artery is considered a visceral (pertaining to
an internal organ of the body) artery. Look in the CPT® Index for Duplex Scan/Arterial Studies/Visceral referring you to code
range 93975-93979. 93976 is the correct code because the venous outflow was not studied.
Next code for the ultrasound. In the CPT® Index, look for Ultrasound/Bladder referring you to 51798. Look for Ultrasound/
Kidney referring you to code range 76770-76776. 51798 is for measurement of post-voiding residual urine which is not
appropriate. 76770-76775 are for ultrasound, retroperitoneal, complete or limited. The examination of the complete urinary
tract (kidney, ureters, and urinary bladder) indicates a complete retroperitoneal ultrasound exam and is reported with
76770. Modifier 26 is used to report the professional component only. According to NCCI edits code 76770 is bundled in code
93976. Diagnostic ultrasound in included in 93976; however, there are two separate reports for two separate studies to be
read by the radiologist. The radiologist must append modifier 59 to 76770 to show the studies were separate. The physician’s
documentation should indicate the medical necessity for the renal ultrasound.
ICD-10-CM code: The history indicates renal artery stenosis. The impression indicates stenosis of both renal arteries. Look
in the ICD-10-CM Alphabetic Index for Stenosis/artery NEC/renal artery referring you to I70.1. The “probable” renal cysts
indicated on the renal and bladder ultrasound should not be coded because it is a probable and not definitive diagnosis
(ICD-10-CM guideline IV.H.). Verify code selection in the Tabular List.
Case 9
Location: Regional Hospital |1|
Examination:
1. CT enteroclysis (fluoro enteroclysis with CT abdomen |2| —neutral enteral with iv contrast—2D reformats)
2. CT enteroclysis (fluoro enteroclysis with CT pelvis |3| —neutral enteral with IV contrast—2D reformats)
Clinical Indication: Unexplained abdominal pain and diarrhea, as well as weight loss. |4|
Normal colonoscopy.
Comparison: None.
Procedure: In accordance with policy and procedure standard medication reconciliation was performed by the radiologic
technologist prior to IV contrast administration. |5| No contraindication was identified.
The examination was performed in accordance with the standard protocol on a 43-year-old male.
Following preprocedure assessment, informed consent was obtained. Conscious sedation: Independent observation performed
by Amy Smith, RN. Total Time of Sedation: 60 minutes |6|. Vital signs, pre- and post-procedure monitoring were done by nurse
in attendance with me performing the conscious sedation |6|. A transnasal intubation was done following a nasal drop of a local
anesthetic.
Under fluoroscopic guidance, |7| using guidewire and positional maneuvers, the enteroclysis catheter was advanced and the tip
anchored at the distal horizontal duodenum. |8|
Neutral enteral contrast was infused and monitored to a total of approximately 3.5 L. 0.6 mg Glucagon was administered IV prior
to IV contrast administration. CT acquisition was done during continued infusion of enteral contrast following a 45 to 50 seconds
delay. Intravenous administration of 100 ml lsovue 370 at 4 ml/second infusion rate. CT parameters used were 40 x 0.625 mm
collimation reconstructed at 2 mm section thickness reconstructed at 1 mm intervals. The source images were transferred to an
independent workstation (EBW) and cross referenced multiplanar interactive 2D interpretation was done by the radiologist. Images
were reviewed using soft tissue window settings.
Following completion of the infusion, the catheter was withdrawn into the stomach and refluxed contrast removed prior to catheter
removal.
No acute adverse events occurred.
Findings: There is no evidence of transmural inflammatory disease changes involving the small bowel or the colorectum. There is,
however, mild prominence of the vasa recta in the right lower abdomen, mild increased attenuation of the cecum and ascending
colon and adjacent distal small bowel. Suggest biopsy at the ascending colon to exclude microscopic colitis. If the patient has a
history of blood in the stools, air double-contrast enteroclysis would be of value to exclude aphthous ileitis. CT enteroclysis may not
be able to assess for early Crohn’s until transmural involvement is seen. The rest of the colon also appears normal.
There are no fold changes to suggest adult celiac disease.
There is no evidence of a small bowel mass. The mesentery appears normal.
Solid abdominal organs are grossly unremarkable.
Impression:
1. No evidence of transmural inflammatory disease changes involving the small bowel or colorectum. No fold abnormalities to
suggest sprue.
2. Prominence of vasa recta of cecum and ascending colon and distal ileum with question of mild increased attenuation.
Consider microscopic colitis. |9| See discussion and recommendation above.
If there is strong clinical suspicion of Crohn’s disease, consider air DC barium enteroclysis to exclude or confirm early aphthoid
changes.
3. Reproduction of abdominal pain |10| during contrast infusion, thus, correlated for visceral hypersensitivity.
4. Solid abdominal organs grossly unremarkable.
|1| Procedure performed at a hospital, only the professional component will be reported by the physician.
|2| CT Abdomen with contrast.
|3| CT Pelvis with contrast.
|4| Reason for exam to be used if no definitive diagnosis is made.
|5| The contrast is administered via IV.
|6| Conscious sedation was used. The presence of an independent trained observer to assist in the monitoring, the total time and
performed by the physician.
|7| Fluoroscopic guidance used.
|8| A tube placed through the nasal opening to the duodenum would be considered a long gastrointestinal tube.
|9| No definitive diagnosis—questionable diagnosis are not coded.
|10| Abdominal pain should be coded.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 74177-26, 74340-26, 44500, 99152, 99153×3
ICD-10-CM codes: R10.9, R19.7, R63.4
Rationale:
CPT® codes: To find the code for tube placement, look in the CPT® Index for Placement/Nasogastric Tube referring you to
43752; however, when you look at the parenthetical instructions under 43752, you are directed to CPT® codes 44500 and
74340 for enteric (pertaining to the small intestines) tube placement. Placement of a long gastrointestinal tube is reported
with 44500. In looking at the parenthetical instructions, the supervision and interpretation of the tube placement is reported
with 74340. To report the CT scans, look in the CPT® Index for CT Scan/with Contrast/Abdomen and CT Scan/with Contrast/
Pelvis. CT scans of the abdomen and pelvis are reported with code 74177. Modifier 26 is used on the radiological codes to
report the professional component only. Moderate sedation was given. Look in the CPT® Index for Sedation/Moderate. Report
code 99152 for a patient five years old and older for the first 15 minutes. Report add-on code three times for the remaining 45
minutes of conscious sedation.
ICD-10-CM codes: There is no definitive diagnosis in the impression; therefore, the reason for the study is used. In this case,
code unexplained abdominal pain. In the ICD-10-CM Alphabetic Index, look for Pain(s)/abdominal referring you to R10.9.
Look in the Alphabetic Index for Diarrhea referring you to R19.7 and look for Weight loss referring you to R63.4. Verify code
selection in the Tabular List.
Case 10
Location: Regional Hospital |1|
Type of Procedure:
1. Abdominal aortic angiogram
2. Mesenteric artery angiogram
History: Mesenteric ischemia. |2|
Informed Consent: The procedure was discussed with the patient and his wife. The risks, including bleeding, infection, and
vascular injuries such as dissection, perforation, thrombus, and embolus were outlined. Informed consent was obtained.
Contrast: 123 mL Ultravist 370.
Description of Procedure: The patient’s right groin was sterilely prepped and draped. The skin and subcutaneous tissues were
anesthetized with 2% lidocaine. The right common femoral artery was then percutaneously accessed and a wire advanced into the
abdominal aorta |3| under fluoroscopic visualization. A 5-French vascular sheath was placed into the right groin. An Omni Flush
catheter was advanced to the upper abdominal aorta. Digital subtraction angiography of the abdominal aorta was performed.
It demonstrates mild tortuosity of the aorta. The caliber is normal. A single renal artery is seen bilaterally without stenosis. The
common iliac vessels are patent.
The Omni Flush catheter was then exchanged for a Cobra 2 catheter. The superior mesenteric artery was then selectively
catheterized. |4| Digital subtraction angiography was performed in multiple obliquities. The origin is patent. No focal stenosis
or branch occlusions are identified. Next, the celiac artery was selectively catheterized. Digital subtraction angiography was
performed in 2 obliquities. The origin is normal. No focal stenosis or branch occlusions are present.
Next, attempts were made to catheter the inferior mesenteric artery with the Cobra 2 catheter. This was unsuccessful. Selective
catheterization of the inferior mesenteric artery |5| was achieved with a Simmons 2 catheter. Digital subtraction angiography was
then performed in 2 obliquities. The origin is patent. No stenosis or branch occlusions are present. The Simmons 2 catheter was
removed as was the right groin sheath over a wire. Hemostasis in the right groin was then achieved using an Angio-Seal closure
device.
Impression: Normal |6| abdominal aortic angiogram and mesenteric angiogram of selective catheterization of the celiac, superior
mesenteric and inferior mesenteric arteries.
|1| The hospital will report the technical component. Only the professional component should be reported.
|2| Reason for the angiogram.
|3| The abdominal aorta is commonly accessed through the common femoral artery.
|4| Selective catheterization of the SMA (Superior Mesenteric Artery). From the aorta, this is a first order.
|5| Selective catheterization of the IMA (Inferior Mesenteric Artery). From the aorta, this is a first order.
|6| The findings were normal, the reason for the angiogram will be used for the diagnosis.
What are the CPT® and ICD-10-CM codes reported?
CPT® codes: 36245, 36245-59, 36245-59, 75726-26, 75726-26-59, 75726-26-59
OR
36245, 36245-59 x 2, 75726-26, 75726-26-59 x 2
ICD-10-CM code: K55.9
Rationale:
CPT® codes: Catheter placement into the aorta is coded with CPT® code 36200; however, because the physician went on to
selective catheterization, the selective catheterizations are coded and 36200 is inclusive (not billed separately). Selective
catheterization from the aorta of the superior mesenteric artery is first order. The selective catheterization from the aorta
of the celiac and inferior mesenteric arteries are also first order (refer to appendix L in your CPT® code book). 36245 is
coded for each first order (SMA, celiac & IMA). This is found in the CPT® Index by looking for Selective Catheterization/
Arterial/First Order/Abdominal. The mesenteric arteries are considered visceral arteries. The imaging supervision and
interpretation (S&I) code reported is 75726 is found in the CPT® Index under Angiography/Abdomen for the first mesenteric
artery. The aortography 75625-26 is bundled with the visceral angiography. Do not report 75774, Angiography, selective,
each additional vessel studied after basic examination. Each vessel was examined; therefore, 75726 is reported x3 for the
superior mesenteric, the celiac, and the inferior mesenteric. The Angio-Seal device placement is included in the selective
catheterization procedures. Code 75774 would be used if, for example, selective catheterization was performed in the celiac
artery (36245) and angiography (75726-26) was performed. Next the catheter was advanced passed the common hepatic
artery (36246) into the left hepatic artery, third order (36247), and angiography was performed (75774-26). The first order
(36245) is now dropped and replaced with the highest order (36247). Only report 75774 when after the basic examination of a
visceral artery (75726), the artery is further investigated. In this case there was no further examination of the three arteries.
Modifier 26 should be used to show only the professional component.
ICD-10-CM code: The angiogram is ordered for mesenteric ischemia. The findings were normal, so mesenteric ischemia will
remain the diagnosis. Mesenteric ischemia is a type of intestinal ischemia. To find in the ICD-10-CM Alphabetic Index look
for Ischemia. Mesenteric ischemia can be acute or chronic. There is no indication in the record of either acute or chronic.
There is an entry under Ischemia, ischemic/intestine referring you to K55.9 which is for unspecified. There is also a subterm
under Ischemia/intestine for due to mesentery artery insufficiency, but there is no indication in this record to suggest the
insufficiency. If mesentery insufficiency were documented, it would be coded as chronic intestinal ischemia K55.1.