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Oncology & Hematology Coding Alert

Coding Specificity is Crucial for CAT Scan Reimbursement

- Published on Sun, Apr 01, 2001
When coding computerized axial tomography (CAT) scans, coders need to be aware of what test the physician ordered so they dont bill for services that were not done. In addition, they should know of any other tests that were administered on the same day that might affect how subsequent scans are coded.

One problem, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies in Dallas, Ga., is that doctors orders often do not match the codes on the claim. For example, a practice may include 74150 (computerized axial tomography, abdomen; without contrast material) and 72192 (computerized axial tomography, pelvis; without contrast material) when only the abdomen was ordered. Scanning of the abdomen is generally performed to study the viscera and/or retroperitoneal structures.

Medicare specifically defines abdomen, as the area between the dome of the liver and the inferior aspects of the kidneys only. It does not include structures below the pelvic brim.

With the above definition in mind and Parmans warnings about matching codes to orders, coders should use the scenarios below as a guideline:

Abdomen only. 74150-74170.

Pelvis only. 72192-72194.

Coincidental scan of abdomen and pelvis. The radiologist performing the procedure may scan the wider area intentionally or coincidentally and indicate that both the abdomen and pelvis were scanned, prompting both areas to be accounted for in the coding. If the pelvic scan was coincidental and not included in the physicians orders, only 74150 should be listed.

Intentional scan of abdomen and pelvis. When an abdominal and pelvic CAT scan are ordered and performed on the same date, the procedures should be reported using two different codes: 74150, 74160 or 74170; and 72192, 72193 or 72194.

Intentional scan of abdomen and portion of pelvis. When it is medically necessary to include significant slices (views) of the upper pelvis when performing an abdominal CAT, the service should be billed with the higher-valued abdomen exam codes, 74150-74170, and the lower-valued pelvis exam codes, 72192-72194, with modifier -52 (reduced services), says Jim Hugh, MHA, senior vice president with AMAC, a reimbursement and billing firm based in Atlanta. This coding scenario accounts for both areas, but does not seek full reimbursement for a partial pelvic scan.

Use Specific Diagnosis Codes

Specificity is crucial, Hugh says. His reminder to use the proper diagnosis code is not rudimentary advice, but a bell toll acknowledging how easily a CAT scan be denied because of its absence. Local medical review policies list a host of codes that prove medical necessity. They must be used at their highest level of specificity and submitted as the principal diagnosis, he says. For example, there are 15 diagnosis codes for intestinal and colon cancer. Physicians are [...]

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