AMA Clinical Examples in Radiology - 2019 Issue 4 (Fall)
Questions and Answers
QUESTIONS AND ANSWERS Question Answer What is the American College of Radiology's (ACR's) position on the appropriate code(s) to report computed tomography (CT) for prosthesis planning and CT radiation planning studies? The hospital, which owns the equipment, would like the radiologists to provide a report on the CT findings and incidental findings of the CT planning studies for the orthopedists and radiation oncologists, respectively. Our group's coding team indicated that in the past, only a technical fee would be allowed, and that a professional component should not be charged. (See the May/June 2009 issue of the ACR Radiology Coding...
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Article Overview
This Q&A article from Clinical Examples in Radiology summarizes ACR guidance on several radiology coding and documentation topics. It discusses billing approaches for CT studies used in prosthesis planning and radiation treatment planning, documentation and reporting considerations for PICC placement with different imaging or localization methods, and how breast abnormality location may be described for reporting and ICD-10-CM coding. The article is useful for radiologists, radiology coders, and billing staff seeking general guidance on how these scenarios are addressed in professional coding references and related CMS guidance.
Why This Topic Matters
These topics affect how radiology services are documented, reported, and billed, especially when imaging is used for planning rather than standard diagnostic interpretation. Accurate understanding helps coding and compliance teams align documentation with the reporting conventions discussed by ACR and CMS.
Article Sections
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CT prosthesis planning and radiation treatment planning
Discusses radiology coding questions related to CT studies performed for planning purposes and the differences between split billing and global billing approaches. It also addresses general reporting considerations for diagnostic versus non-diagnostic use of CT data.
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PICC placement and ultrasound documentation
Reviews documentation expectations for PICC placement when ultrasound or other guidance is used. The section also covers how incomplete documentation affects reporting in relation to image-guided and non-imaging-guided PICC services.
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Image-guided PICC placement and tip confirmation
Addresses PICC coding when imaging guidance is used for insertion but catheter tip verification is performed with a nonimaging system. It also notes the relationship between documentation of final catheter position and reduced-services reporting.
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Breast abnormality location reporting
Explains general approaches to describing breast lesion location in mammography and breast ultrasound reports. It references ACR and CMS guidance on how location terminology relates to coding specificity and quadrant reporting.
What You Will Learn
- How radiology Q&A guidance distinguishes planning studies from diagnostic interpretations
- What documentation themes are emphasized for PICC placement services
- How nonimaging tracking or localization systems are treated in relation to imaging guidance
- How breast abnormality location terminology is discussed in relation to ICD-10-CM reporting
Who Should Read This
- Radiologists
- Radiology coders
- Medical billing staff
- Compliance professionals
- Imaging department administrators
Codes Discussed
Modifiers Discussed
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