Radiology Coding Alert

Don't miss the ACR's guidance on abdominal and pelvic CTs Get a leg up on common urology imaging issues with the answers to three commonly asked coding questions. Overcome Abbreviation Troubles Question 1: We have one urologist who likes to send orders using abbreviations, such as CT Stone Protocol or CT Scan Abdomen/Pelvis I-. How can we make sure we have adequate information to code? Answer: A protocol isn't the same as an order, and protocols vary from region to region and specialty to specialty, says Carla Mulcay, CPC, CPC-H, RCC, assistant director of coding for MedQuest Associates in Alpharetta, Ga., which operates independent, fixed-site, diagnostic imaging centers.

Protocol has no meaning in CPT Codes , so there's no way to code correctly if that's all the information you have, she adds.

An unusual abbreviation such as I- is a red flag in audits and makes coding difficult. Documentation should only include standard abbreviations--if it includes any at all, Mulcay says. (Some providers use I- to indicate without ionic contrast and I+ for with ionic contrast.)

Solution: Use a standard CT order form that lists several options, she says.

Example: You can base your form on this sample from Mulcay.

Contrast:  ___Without    ___With    ___W&WO    ___Radiologist Discretion Perform 3D/Multi-Plane Reconstructions (If Necessary): __Yes   __ No   __ Renal Mass Protocol (Abdomen with and without contrast)
  __ Stone Protocol (Abdomen contrast)
  __ Other (Specify)                               
Now your documentation will include the order for x  Stone Protocol (Abdomen & Pelvis without contrast), rather than a confusing abbreviation or protocol.

Watch for: Radiological procedures also require a written report signed by the interpreting physician, and documentation of medical necessity.

How to code: Report the abdominal CT without contrast with 74150 (Computed tomography, abdomen; without contrast material) and the pelvic CT without contrast with 72192 (Computed tomography, pelvis; without contrast material). Earmark These 8 Diagnosis Codes Question 2: Which diagnosis codes will we typically use for tests ordered by urologists?
 
Answer: Avoid the temptation to guess the patient's diagnosis based on typical urological diagnoses. 

And of course you shouldn't include or exclude certain codes based on what your payer will cover, says Margaret Gambill, RHIA, CCS-P, with BKD Health Care Group.

Only code what the clinical information reveals.

Keeping that in mind, diagnoses resulting from tests ordered by urologists may include the following:

Renal mass: 593.9--Unspecified disorder of  kidney and ureter

Renal cancer: 189.0--Malignant neoplasm of kidney and other and unspecified urinary organs; kidney, except pelvis

Renal neoplasm, benign: 223.0--Benign neoplasm of kidney and other urinary organs; kidney, except
pelvis

Adrenal disorders: 255.x--Disorders of adrenal glands

Renal stone: 592.0--Calculus of kidney

Ureteral calculus: 592.1--Calculus of ureter

Renal cyst: 593.2--Cyst of kidney, acquired

History of kidney cancer: V10.52--Personal history of malignant neoplasm; kidney. Remember: Your [...]