Radiology Coding Alert

What CPT code(s) should be used for a CT scan from the diaphragm to the pubis? asks a radiologist from Virginia. The obvious coding solution is to use both 74150 (CT abdomen) and 72192 (CT pelvis) when scanning all the way from diaphragm to pubis; 74150 when scanning upper abdomen only; and CPT 72192 when scanning the pelvic area only. However, in the real world of clinical radiology practice the matter is not so simple.

Define Between Abdomen and Pelvis

The American College of Radiology (ACR) provides a standard for these procedures in its Standard for the Performance of Computed Tomography of the Abdomen and Pelvis (for a copy, call 703-648-8987). This draws an artificial line between abdomen and pelvis.

According to the ACR, the reference points for a CT of the abdomen are from the top of the diaphragm to the top brim or border of the pelvic bone known as the iliac crest. The reference points for a CT of the pelvis are from the iliac crest to the lower end of the pelvic bone known as the ischial tuberosity. On the harder question of when to do both exams, the ACR standard states, Often, depending on the clinical circumstances, both the abdomen and pelvis must be examined. The key words here are often and both the abdomen and pelvis must be examined; and that the decision is depending on the radiologists evaluation of clinical circumstances.

Coding When Referrals are Vague

From a coding perspective, the definitions and guidance in the ACR standard help. However, the radiologist still has to deal with vague or incorrect indications and inappropriate exam orders from referring physicians who may not be familiar with or aware of CT standards or protocols. The radiologist also remains responsible for clinical evaluation of indications to decide when abdominal and/or pelvic CT is appropriate. To understand the importance of indications received from the referring physician, as well as the challenge faced by the radiologist trying to do the right exams as efficiently as possible the first time, consider the following actual case:

A patient is referred from the emergency room with right lower quadrant abdominal pain (ICD-9 789.03 ). The referring ER physician suspects appendicitis (540.9) and refers to radiology where protocol for evaluation of appendicitis calls for CT pelvis (72192), which is performed with negative results. The patient is admitted and upon further evaluation is sent to radiology again, this time for CT of the abdomen (74150), which results in finding inflammation of the kidney (583.9, nephritis) and, upon further CT slices, the discovery of a small kidney stone (592.0, calculus of kidney).

If the radiologist is forced to limit a scan to a portion of the abdominopelvic cavity because a facility interprets the order as pelvis or upper abdomen, the potential for an incomplete evaluation is the result. The problem with a vague indication like abdominal pain is that often the cause is away from the site of the perceived pain. In this case, the results were an incorrect suspicion of appendicitis and hospital admission, both of which may have been avoided if the original imaging included CT of the abdomen to allow correct diagnosis of a kidney stone.

Another common indication for concurrent CT of abdomen and pelvis is pancreatitis (577.0). Unlike abdominal pain, pancreatitis is a specific indication often involving secondary findings away from the pancreas in the upper abdomen, such as abnormal fluid accumulation down in the pelvis (789.5, ascites, fluid in peritoneal cavity).

CODER ALERT: Make sure the referring physicians indications (diagnoses, signs, and symptoms) for the CT match the CT ordered. If the radiologist has any questions about initial indications or exams ordered, the referring physician should be contacted and the order should be properly revised for the record prior to performing the CT to allow correct coding of both indications and CT exams of the abdomen and pelvis. Also, remember to look for additional indications reported by the radiologist upon completion of the CT.