Radiology Coding Alert

Pyelography is frequently used to localize and diagnose disorders of the urinary tract such as kidney stones (ICD-9 Code 592.0, calculus of kidney), and CPT Codes provides a series of codes to describe various techniques used during these procedures (74400-74425). However, many professional coders express confusion about which code to use under which circumstancesand with good reason. The distinctions between them are slight and in some cases do not reflect changes in clinical techniques used during intravenous pyelograms (IVPs).

I simply dont understand this series of codes, the director of one coding department exclaims. The definitions are so closely related that its nearly impossible to know when one should be used as opposed to another. In most cases, my coders fall back to 74400 (urography [pyelography], intravenous, with or without KUB, with or without tomography). Im not sure if this is a correct strategy and would like to get a grasp of these codes.

According to many experienced coding professionals, using 74400 as a catchall code to describe IVPs is entirely appropriate. It was revised several years ago to encompass virtually all aspects of these urography procedures, and most payers reimburse it accordingly. Although CPT 74410 (urography, infusion, drip technique and/or bolus technique) and 74415 (with nephrotomography) remain valid codes and may continue to be assigned, many experts anticipate that they will be eliminated when CPT 5 is published.

Deciding When to Use 74400, 74410 or 74415

The misunderstanding surrounding these codes often occurs because the description for 74400 includes references to intravenous (as does 74410 [drip technique]) and tomography (as does 74415). Its understandable that there has been confusion, says Brian Effron, CHBME, of Healthcare Administrative Partners in Media, Pa., which provides medical billing and practice management services in seven states and also has offices in Newton, Mass., and Portsmouth, N.H. Code 74400 clearly incorporated elements of 74410 and 74415.

Coders report that the uncertainty about assigning these codes has escalated during the past few years as CPT code revisions have not kept pace with the rapidly changing environment of medical imaging.

Traditionally, for instance, radiologists would administer the contrast material using any one of a variety of techniquesi.e. infusion, drip technique or bolus. If the technique was clearly stated in the medical report, a coder would have assigned 74410. If no technique was documented, 74400 would have been used. In recent years, however, virtually all IVPs have been performed using bolus injections and the need to record a distinction has become mootas has any reason to assign code 74410.

In addition, specific use of 74415 has become unnecessary, for the simple reason that the terms tomography and nephrotomography can be used interchangeably, Effron points out. Tomography is a technique for taking radiographic images of an organ that shows specific slices or planes of the organ. Nephrotomography is simply an alternate term that specifically describes tomography as it applies to imaging of the kidneys.

In short, thanks to these imaging advances, experts say coders may feel comfortable disregarding these two outdated, inapplicable codes and using the most recently modified 74400 for all IVPs.

Correctly Assigning 74420 and 74425

A retrograde examination of the ureter and intrarenal collection system is reported using code 74420 (urography, retrograde, with or without KUB), notes Laura Siniscalchi, RHIA, CCS, CCS-P, CPC. This procedure involves introducing a catheter into the urinary tract through the urethra and assessing the backward flow through the system. The contrast injection is most often performed by a urologist in an operating or cytoscopy suite, and the resultant images are interpreted by the radiologist.

On the other hand, 74425 is applied to antegrade examinations (urography, antegrade, [pyelostogram, nephrostogram, loopogram], radiological supervision and interpretation), which is a surgical procedure because the physician cannot use a natural body opening like the urethra. This percutaneous procedure allows the radiologist or urologist to inject contrast directly into the urinary system to assess the flow of urine anywhere along the tract in a forward-moving sequence from the kidneys, through the ureters and into the bladder, explains Siniscalchi, education coordinator for coding at Beth Israel Deaconess Medical Center in Boston.

Code 74425 describes a percutaneous study and is assigned for the RS&I (radiological supervision and interpretation) services only, adds Ellen Ratnofsky, RN, BSN, CS, who works with Effron. To report the injection of contrast material, coders would also assign one of three additional codes.

These codes include:

50394: Injection procedure for pyelography [as nephrostogram, pyelostogram, antegrade pyeloureterograms] through nephrostomy or pyelostomy tube, or indwelling ureteral catheter;

50684: Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter; and

50690: Injection procedure for visualization of
ileal conduit and/or ureteropyelography, exclusive of radiologic service.