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CHAPTER 28 RADIOLOGY Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 1 Radiology • Radiology: Branch of medicine that uses ______ radiant energy to diagnose and treat patients • Specialist in radiology: _________ Radiologist (doctor of medicine) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 2 Radiology Subsections • Diagnostic Radiology – Aorta & arteries • Diagnostic Ultrasound • Radiologic Guidance • Breast, Mammography • Bone/Joint Studies • Radiation Oncology – Clinical Brachytherapy • Nuclear Medicine Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 3 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 4 Magnetic Resonance Imaging • MRI uses magnetic energy to view ___ soft tissue structures lumbar spine canal – Example: 72148, MRI of ______ (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 5 MRI (…Cont’d) Figure: 28.12 Modified from Bradley WG, Daroff RB, Fenichel GM, Jankovic J: Neurology in Clinical Practice, ed 5, Philadelphia, 2008, Butterworth-Heinemann. • MRA—Magnetic Resonance Angiography—is application of MRI that provides visualization of blood flow, as well as images of normal and diseased blood vessels Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 6 Tomography or CT • Tomography used to view single _____ plane of body – Example: 70450, Tomographic scan of head or _____ brain (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 7 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.) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 8 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 9 Planes of Body • Imaginary lines used as points of reference Figure: 28.1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 10 Position and Projection • Position _______: Way in which patient placed Projection Path x-ray beam travels • ________: Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 11 Terminology • Radiology uses a wide variety of terms and abbreviations specific to planes, positions, and projections Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 12 Component Coding • Three component terms Professional – __________ – Technical ________ – ______ Global Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 13 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. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 14 Technical Component (-TC) • Technologist’s services • Equipment, ___, film and supplies From Long BW, Frank ED, Ehrlich RA: Radiography Essentials for Limited Practice, ed 4, St. Louis, 2013, Saunders. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 15 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 16 Component Modifiers • If only professional component of -26 to radiology service provided append ___ code (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 17 Component Modifiers (…Cont’d) • If only technical component was provided append -TC ___ to code – -TC: HCPCS modifier used with CPT and HCPCS codes Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 18 Global Procedure • If both professional and technical components of radiology service provided, use no __ modifier (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 19 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…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 20 Global Procedure (…Cont’d) • Third-party payers usually reimburse – 40% professional component – 60% technical component – 100% global procedure Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 21 Contrast Material • Statement “with contrast” implies _______ injection built into code (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 22 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” Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 23 Overview of Radiology Subsections • Diagnostic Radiology • Diagnostic Ultrasound • Radiologic Guidance • Breast, Mammography • Bone/Joint Studies • Radiation Oncology • Nuclear Medicine Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 24 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…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 25 Diagnostic Radiology (…Cont’d) • Used to: – Diagnose disease – Monitor disease process—progression or remission Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 26 Diagnostic Procedures Include • X-ray Subdural hematoma • Computerized axial tomography (CAT or CT __ scan) • Magnetic resonance imaging (MRI) From Mettler FA: Essentials of Radiology, ed 3, Philadelphia, 2014, Saunders. CT of renal artery • Angiography From Mettler FA: Essentials of Radiology, ed 3, Philadelphia, 2014, Saunders. From Walsh PC, editor: Campbell's Urology, ed 8, Philadelphia, 2002, Saunders. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 27 Computerized Axial Tomography • X-ray image taken in sections • Computer reconstructs and enhances ________ image Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 28 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 29 Angiography • Used to view vessel obstructions • Dye ___ injected into vessel (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 30 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. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 31 Angiography (…Cont’d) • Radiologist uses angiography to diagnose vascular conditions • Examples: – Malformations – Strokes – Myocardial infarctions Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 32 Remember • If fewer than total number of views specified in code provided: – Use -52 ___, Reduced Service Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 33 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…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 34 Diagnostic Ultrasound (…Cont’d) • Ultrasound showing a gallstone Figure: 28.14 From Goldman L, Schafer AI, editors: Goldman's Cecil Medicine, ed 24, Philadelphia, 2012, Saunders. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 35 Subheadings • Subheadings of Diagnostic Ultrasound primarily based on anatomy ________ • Example: – Head and Neck – Chest – Pelvis • Many notes in subsection directing correct assignment Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 36 Three Locations For Ultrasound Services • 76506-76999: Radiology codes for ________ ultrasound services diagnostic • 93880-93998: Medicine codes for vascular _______ studies • 93303-93352: Medicine codes for echocardiography Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 37 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) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 38 Ultrasound Modes and Scans • __-mode or A-scan technology— A one-dimensional • __-mode—one-dimensional measurement M procedure with movement of trace to allow amplitude and velocity of moving echoproducing structures • __-scan technology—two-dimensional B • Real-time scan • A & B scan may be performed together (medical necessity documented) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 39 A-Mode • A = _________ Amplitude • Technique used to map structure outline • Displays one ___-dimensional image Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 40 M-Mode • M = Motion ______ • Technique used to display movement of structure • Displays one ___-dimensional image Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 41 B-Scan • B = Brightness _________ • Technique used to display movement of tissues and organs • Known as ____ gray scale ultrasound • Displays ___-dimensional image two Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 42 Real-Time Scan • Technique used to display both _______ structure and ______ motion with time of organ and tissues • Displays ___-dimensional image two Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 43 Extent of Study • Codes often divided on extent of study • Example: Extent of scan as follows (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 44 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 45 Radiologic Guidance, Breast, Mammography, Bone/Joint Studies, and Radiation Oncology • Radiologic Guidance (77001-_____) 77022 – Fluoroscopic, computed tomography, magnetic resonance guidance, and other 77051 • Breast, Mammography (_____-77059) – Such as screening, and computer-aided detection • Bone/Joint Studies (77071-_____) 77084 – Such as bone density and joint survey 77261 • Radiation Oncology (_____-77799) – Therapeutic use of radiation – Codes for both professional and technical services – Subheading divided based on treatment Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 46 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 47 Clinical Treatment Planning— Professional Component • Includes: – Interpretation of special testing – Tumor localization – Determination of treatment volume (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 48 Clinical Treatment Planning (…Cont’d) • Choice of treatment method • Determination of number of treatment ports • Selection of treatment devices • Other necessary procedures (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 49 Clinical Treatment Planning (…Cont’d) • Clinical Treatment Planning consists of – Three types of treatment plans – For all patients requiring radiation therapy Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 50 Levels of Planning (77261-77263) • 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…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 51 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) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 52 Simulation (77280-77293) • Determines placement of treatment areas/ports for radiation treatment • Does not include administration of _______ radiation (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 53 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 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 54 Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services (77295, 7730077370) • Decision-making services of physicians – Treatment types placement (dosimetry) – Dose calculation and _________ – Development of treatment device • Stereotactic Radiation Treatment Delivery (77371-_____) 77373 – Pay close attention to notes • Delivers large dose to specific tumor site Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 55 Radiation Treatment Delivery (77401-77525) • Radiation (77401-77421) • Neutron Beam (77422, 77423) • Proton Beam (77520-77525) • Technical component of actual delivery of radiation – MeV (electrons) – Neutrons – Protons Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 56 Information Needed to Code Radiation Treatment Delivery • Amount of radiation delivered • Type of radiation—_______ electron (most common), neutron, or proton (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 57 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) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 58 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 additional fraction – Count the last 3-4 as an ________ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 59 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. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 60 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…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 61 Clinical Brachytherapy Codes Divided Based On (…Cont’d) • Number of sources applied: – Simple: 1_-4 – Intermediate: 5-__ 10 – Complex _______: 11+ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 62 Nuclear Medicine • Placement of radioactive material into measurement of emissions body and ____________ • Used both for diagnosis and treatment – Example: Stress test (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 63 Nuclear Medicine (…Cont’d) • Codes divided primarily on organ system – Exception: “Therapeutic,” for radiopharmaceutical therapies Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 64 Positron Emission Tomography (PET) • 78811-_____ 78816 PET imaging of Hodgkin’s lymphoma (the arrows indicate the site of the disease.) location • Based on _______ (such as skull base or chest) • Non-invasive imaging procedure that assesses perfusion and level of metabolic activity in various organ systems From Goldman L, Schafer AI, editors: Goldman's Cecil Medicine, ed 24, Philadelphia, 2012, Saunders. Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 65 Conclusion CHAPTER 28 RADIOLOGY Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 66