AMA Clinical Examples in Radiology - 2020 Issue 4 (Fall)
Questions and Answers
QUESTIONS AND ANSWERS Question Answer What are the documentation requirements to report breast tomosynthesis? If tomosynthesis is not mentioned in the technique section, but the use of tomosynthesis is stated elsewhere in the report (eg, in the views obtained section), is that sufficient? In mammography, as in all imaging, it is important to accurately describe the study performed so coders can accurately identify the correct Current Procedural Terminology (CPT®) code to report. In the case of mammograms and tomosynthesis, the technique is the views obtained. It is acceptable, but not necessary, to have two separate sections. As long...
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Article Overview
This Q&A article reviews several radiology coding scenarios and related documentation considerations. It is useful for coders, billers, radiology staff, and compliance teams who need a broad understanding of how guidance connects imaging documentation with current CPT, HCPCS, and Medicare-related reporting changes.
Why This Topic Matters
Radiology coding often depends on how the study is documented, what type of imaging was performed, and whether a service is bundled or separately reportable. This article helps readers understand the scope of documentation and reporting topics covered so they can determine whether the full premium content is relevant to their work.
Article Sections
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Breast tomosynthesis documentation
Discusses documentation concerns for mammography studies that include tomosynthesis and the general relationship between study description and code selection.
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Antegrade pyelogram through new versus existing access
Covers reporting considerations for antegrade urinary collecting system imaging when access is newly created versus already present, along with related bundled-code discussion.
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CT simulation and IMRT planning
Addresses reporting considerations for CT simulation in the context of intensity modulated radiotherapy planning, including Medicare-related edit and payment references.
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Low-dose CT lung cancer screening code change
Summarizes a reporting update involving lung cancer screening CT and the transition from a deleted HCPCS code to a CPT code for 2021.
What You Will Learn
- How the article frames documentation issues for breast imaging studies involving tomosynthesis
- How reporting differs for antegrade urinary tract imaging based on the type of access
- How CT simulation is discussed in relation to IMRT planning and Medicare edits
- What general type of coding update affected low-dose CT lung cancer screening reporting in 2021
Who Should Read This
- Radiology coders
- Medical billers
- Radiology departments
- Compliance staff
- Revenue cycle professionals
Codes Discussed
Code Ranges Discussed
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