Positions and placement

Terminology referring to planes of the body and positioning of the body is often used in the Radiology section. A position is how the patient is placed during the x-ray examination, and a projection is the path of the x-ray beam. Figure 3-1 illustrates the major planes and the surfaces of the body that can be accessed by positioning the body.

Figure 3-2 shows proximal and distal directional body references that mean closest to (proximal) or farthest from (distal) the trunk of the body. These terms are relative, meaning they are used to describe the position of the part as compared with another part. Therefore, the term proximal describes a part as being closer to the body trunk than another part, and the term distal describes a part as being farther away from the body trunk than another part. The knee would be described as being proximal to the ankle, and it would also be described as being distal to the thigh or hip.

Figure 3-3 illustrates the anteroposterior (AP) (front to back) position, in which the patient has his or her front (anterior) closest to the x-ray machine, and the x-ray travels through the patient from the front to the back. In Figure 3-4, the posteroanterior (PA) position, the patient has his or her back (posterior) located closest to the machine, and the beam travels through the patient from back to front.

Lateral positions are side positions. When the patient’s right side is closest to the film, it is called right lateral. When the patient’s left side is closest to the film, it is called left lateral. Figure 3-5 shows a left lateral position, and Figure 3-6 shows a right lateral position. The use of these various positions allows the physician to view the body from a variety of angles.

Dorsal, more commonly referred to as supine, means lying on the back (sUPine means lying on the back with the face UP); ventral, more commonly referred to as prone, means lying on the stomach; and lateral means lying on the side.

Decubitus positions are recumbent positions; the x-ray beam is placed horizontally. Ventral decubitus (prone) is the act of lying on the stomach (Figure 3-7, A), and dorsal decubitus (supine) is the act of lying on the back (Figure 3-7, B). The term “decubitus,” generally shortened to “decub,” has a special meaning in radiology. The simple act of lying on one’s back would be referred to as lying supine, but if a horizontal x-ray beam is used, the position becomes decubitus. The type of decubitus is determined by the body surface on which the patient is lying.

Recumbent means lying down. Thus, right lateral recumbent means the patient is lying on the right side (Figure 3-7, C), and left lateral recumbent means the patient is lying on the left side (Figure 3-7, D). In the ventral decubitus position, the patient is positioned prone, and the x-ray beam comes into the patient from the right side and exits on the left (Figure 3-7, E).

In the left lateral decubitus position, the patient is lying on the left side with the beam coming from the front and passing through to the back (anteroposterior) (Figure 3-7, F).

When the patient is positioned on his or her back (dorsal decubitus) and the x-ray beam comes into the left side of the patient, the positioning is dorsal decubitus, but the view obtained is a right lateral (because the right side is closest to the film) (Figure 3-7, G).

Oblique views refer to those obtained while the body is rotated; it is not in a full anteroposterior or posteroanterior position but is somewhat diagonal. Oblique views are termed according to the body surface on which the patient is lying. The left anterior oblique (LAO) position is depicted in Figure 3-7, H, with the patient’s left side rotated forward toward the table. The patient is lying on the left anterior aspect of his or her body. The right anterior oblique (RAO) position has the patient on his or her right side rotated forward toward the table, as in Figure 3-7, I.

Two more oblique views are left posterior oblique and right posterior oblique. In the left posterior oblique (LPO) view, the patient is rotated so that the left posterior aspect of his or her body is against the table, as in Figure 3-7, J. The right posterior oblique (RPO) view has the patient on the right side rotated back, as in Figure 3-7, K.

Tangential is the patient position that allows the beam to skim the body part, which produces a profile of the structure of the body (Figure 3-8, A). Figure 3-8, B illustrates the axial projection, which is any projection that allows the beam to pass through the body part lengthwise.

Odontoid is a view with the patient’s mouth open. Swimmers is a position in which the arms are over the head.

Component coding

Coding radiology services often includes component coding. The following are components:

When reporting Radiology services it is important that you determine if you are billing for the global component (both the technical and professional), professional, or technical only.

Global Component—When reporting both the professional (physician/radiologist) and technical portion (resources used such as equipment and supplies) of the service, report the CPT code without a modifier -26 or -TC, because this would inform the carrier that you are submitting for both the professional and technical portion of the service. For example, if the orthopedic physician owns the x-ray equipment located in his office, employs the technician, and also provides the supervision and report, a global service was provided, and the CPT code would not require a modifier -26 (professional component) or -TC (technical component).

Professional Component—When reporting the professional portion only of the service, it means that you are only reporting the physician/radiologist’s supervision and interpretation with report and not the technical portion (cost of resources used such as equipment and supplies) of the service. When only the professional (physician) component is provided, report the CPT code with modifier -26 to indicate the physician provided only the professional portion of the service, not the entire service. For example, a radiologist from the local clinic analyzes x-rays taken of a patient at the hospital radiology department. The radiologist prepares a written report of the findings and reports the service with a radiology code with modifier -26 added to indicate that the equipment, film, technical services, and supplies were NOT provided by the physician preparing the report at the time of this service.

Two billing forms are used in the hospital setting: CMS-1500 for professional services provided by professional employees of the hospital and the CMS-1450 (UB-04) to report facility (hospital) services. At times the hospital will employ a radiologist to provide professional services, such as mammography interpretation. Hospital-based physicians may also staff various departments of the hospital, such as the hospital-based radiology department. These physicians may work exclusively for the hospital or may be employed by both the clinic and hospital at the same time. When reporting the services of the physician portion of the service performed by a hospital-employed physician, you would report the professional service on the CMS-1500 with modifier -26. The technical component of the service is reported on the CMS-1450 (UB-04). When reporting the technical component on the CMS-1450 (UB-04), there is no need to add modifier -TC because the CMS-1450 (UB-04) is used to report only the technical component of the services.

At the clinic, both the professional (physician) and the technical components are reported on the CMS-1500. If only the professional component is reported, modifier -26 is added to the code. If only the technical component is provided, modifier -TC is added to the CPT code. If both the professional and technical components are reported, known as global services, the radiology code is reported without a modifier.

Interventional radiology

Sometimes a surgical procedure will be performed with the use of radiologic guidance. This is referred to as interventional radiology. Billing for these types of procedures requires a code from both the Radiology and Surgery sections of the CPT manual. The radiological portion can be performed by a radiologist or interventional radiologist. An interventional radiologist can do both the radiological and surgical part of the procedure. A radiologist can only provide the radiological portion of the service, and the surgical procedure would be performed by the surgeon. The codes in the Radiology section describe the radiologic portion of the procedure only. When a procedure requiring the use of radiology is performed, the services are reported with a combination of CPT codes from the Surgery (for the procedure) and the Radiology sections (for the radiologic Supervision and Interpretation [S&I]). The physician performing the procedure (such as biopsy, aspiration, injection, or placement of other materials) will report his portion of the procedure using a code from the Surgery section of the CPT manual. The physician performing the radiologic supervision and interpretation will report his service using the radiology S&I code. When a single physician performs both the procedure and the radiologic S&I, he will report a combination of codes for each aspect of the procedure. For example, an ultrasound-guided fine needle aspiration is reported with both 10022 and 76942. In addition to performing the S&I, a permanently recorded image and report are required. The above rule regarding the use of a combination of codes does not apply to the Radiation Oncology procedures.

Contrast

Codes in the Radiology section describe only the radiology procedures, not the intra-articular (joint) injection or placement of other materials necessary to provide the service; therefore, these would be reported in addition to the radiology service. For example, contrast material that is injected during a radiographic procedure is reported separately. The phrase “with contrast” in the CPT manual means contrast that was injected. The supply of the injected contrast material is reported with a HCPCS Level II code, such as Q9952, Injection during MRI. If the procedure indicates that contrast was administered orally or rectally, the service is coded as “without contrast” because only intravascular contrast qualifies as “with contrast.”

An intra-articular injection is one that is within a joint. An intrathecal injection is one that is placed through the theca (enclosing sheath) of the spinal cord into the subarachnoid space.

Contrast is typically administered in the following methods:

Many types of contrast are often used with the various radiographic procedures. For example:

Facility specifics

In the outpatient departments of the hospital, CPT codes for the radiologic examination are established by the facility Chargemaster, the computer software program used to process hospital billing. Many facilities have included modifiers programmed within the Chargemaster software. The modifiers automatically are placed on the insurance claim form without any intervention by coding staff.

The main difference in ICD-9-CM coding for the hospital facility in the outpatient setting is the use of Volume 3 for the procedure codes. Chapter 16 of Volume 3, Miscellaneous Diagnostic and Therapeutic procedures (87-99), includes many procedures performed in a radiology department. For example, an x-ray of facial bones is assigned procedure code 87.16 from Volume 3.

Many facilities have specific policies designating which procedures performed within the facility will be assigned codes from Chapter 16. Policies vary between the inpatient and outpatient setting within a hospital facility. These policies are usually reviewed annually because of the rapid changes in technology and the more invasive and complicated procedures that are being performed in the radiology department. For the purposes of this text, most of the invasive radiology procedures (entering the body) are performed in the hospital radiology department. Routine procedures, such as x-rays, CTs, and ultrasounds, are usually performed in the clinic outpatient setting.

Diagnostic radiology

Codes 70010-76999, often used from the Radiology section, include both diagnostic radiology and diagnostic ultrasound. These codes describe diagnostic imaging, computed axial tomography (CAT, CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). The codes are divided by x-ray, CAT/CT, MRI, and MRA throughout the subsection. For example, subheading Spine and Pelvis (72010-72295) includes the following:

If fewer than the total number of views specified in the code are taken, modifier -52 (reduced service) would be used to indicate to the third-party payer that less of the procedure was performed than described by the code unless a code already exists for the smaller number of views.

X-ray is a common diagnostic radiology service. The service can be provided on an outpatient or inpatient basis. Modifier -26 is used to indicate that only the professional component of the service was provided.

CAT/CT scans

Computerized axial tomography (CAT or CT) is a procedure by which selected planes of tissue are pinpointed through computer enhancement. The CAT is produced by means of a circular machine that takes pictures of the patient from many different angles. If needed, a three-dimensional image can be produced. The scan can be with or without contrast (remember that oral or rectal contrasts do not count as contrast). “Without” means there is no IV contrast. “With” means there is IV contrast. The scan can also be performed without contrast followed by with contrast, which means that the scan would be conducted first without contrast and then repeated again with contrast. The codes are usually divided based on the statement of with or without contrast and then the extent of the study. The codes are located in the index of the CPT manual under the term “CT Scan” and further subdivided by “Without and with Contrast,” “Without Contrast,” and “With Contrast.” Locate “CT Scan” in the index of the CPT manual and note that these three divisions list the same or similar subterms, such as “Abdomen” in each division. The “Without and with Contrast” is when the CT scan is performed without contrast first and then repeated with contrast. The “Without Contrast” is the use of no intravenous contrast. The “With Contrast” is with the use of injected contrast.

A technician, under the supervision of a radiologist, performs the scan, and the radiologist interprets the results and writes a report. Do not report modifier -TC if the technical component is provided at the hospital because, as stated earlier, the CMS-1450 (UB-04) does not require the use of the technical modifier. If the radiologist performs only the professional component of the service, modifier -26 is added to the code.

Hypoxemia

Hypoxemia, also known as anoxia, is a deficiency in the level of oxygen in the arterial blood.

For the next three cases, 3-11A through 3-13A, the radiologist is employed by the clinic and is rendering services at the hospital. Assign the professional component only.

CASE 3-11   3-11A CT Scan, Sinuses

CASE 3-11

Report Dr. Hart’s service.

3-11A  CT scan, sinuses

LOCATION: Inpatient, Hospital

PATIENT: Cheryl West

PHYSICIAN: Ronald Green, MD

RADIOLOGIST: Phillip Hart, MD

CLINICAL SYMPTOMS: Intubated due to congestive heart failure, hypoxemia.

COMPUTED TOMOGRAPHIC EXAMINATION OF THE PARANASAL SINUSES was performed using thin, overlapping images in the axial plane. The patient’s condition did not allow direct coronal images. Coronal reconstructions (3-D) were performed from the original data set and required an independent workstation.

Frontal, ethmoid, and sphenoid sinuses are virtually all filled with abnormal soft-tissue density. There is no bone erosion. The septations of the ethmoid complexes remain intact. Nasal cavity shows decreased aeration bilaterally.

Both maxillary sinuses show a considerable amount of abnormal soft-tissue density, but there is some aeration. There certainly could be fluid levels.

There is nasal intubation on the right.

IMPRESSION: Abnormal density almost filling all of the paranasal sinuses, as described above, without bone erosion. Certainly, this might be due to inflammation/infection; however, it is certainly not unusual for fluid to collect within paranasal sinuses when patients are intubated. The findings do need close clinical correlation.

3-11A:

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________

ICD-9-CM DX CODE(S): ___________________________________

CASE 3-12   3-12A CT Scan, Sinuses

CASE 3-12

Report Dr. Hart’s service. Remember to also assign an ICD-10-CM Z code to report the “Dependence, on, ventilator” and an ICD-9-CM V code to report “Dependence, on, respirator [ventilator].”

3-12A  CT scan, sinuses

LOCATION: Outpatient, Hospital

PATIENT: Lonny Barker

PHYSICIAN: Ronald Green, MD

RADIOLOGIST: Phillip Hart, MD

EXAMINATION OF: CT (computed tomography) of sinuses

CLINICAL SYMPTOMS: FUO (fever of unknown origin)

COMPUTED TOMOGRAPHIC EXAMINATION OF THE PARANASAL SINUSES was performed with intravenous contrast in the axial plane, computed for high-resolution bone algorithm. The patient is on a ventilator. Direct coronal images could not be obtained.

The left maxillary sinus is almost completely filled with abnormal soft-tissue density. The right maxillary sinus also shows a considerable amount of abnormal soft-tissue density, and there is a bubble appearance. I believe there is fluid within both sinuses.

Most of the ethmoid sinuses are filled with abnormal soft-tissue density. Septations of the ethmoid complexes are intact. Right sphenoid sinus shows some aeration. There are also mural nodulations of soft tissue within the left sphenoid sinus, but there might be a fluid level.

Both frontal sinuses are well aerated, but there is a rim of mucosal thickening of each frontal sinus, and there may be fluid within the left frontal sinus inferiority.

IMPRESSION: All the paranasal sinuses show abnormalities as described above. Many of the air cells are filled with abnormal soft-tissue density. There is indication of fluid within at least the maxillary sinuses and perhaps the left sphenoid sinus. The findings can be consistent with a sinusitis condition; however, the patient is also on a ventilator. Patients with endotracheal intubation can have fluid in the sinuses without having a sinusitis condition.

3-12A:

SERVICE CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________

ICD-9-CM DX CODE(S): ___________________________________

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