HAP Radiology Billing and Coding Blog

How the 2018 Coding Changes Will Affect Radiology Practices

Posted: By HAP USA on December 15, 2017

How the 2018 Coding Changes Will Affect Radiology Practices Healthcare Administrative Partners.jpgThe recently issued Medicare Physician Fee Schedule (MPFS) Final Rule for 2018 tells us which of the revisions to the Current Procedural Terminology[i] (CPT)® have been adopted for use in the Medicare system, and how Medicare values those codes.  The diagnostic radiology changes are fairly straightforward, but the Interventional Radiology (IR) coding for Endovascular Repair has been drastically altered with 20 new or revised codes. 

Diagnostic Radiology

Mammography

Medicare has made the switch to the new CPT codes that were defined a few years ago.  While most commercial payers stuck with the Medicare G-codes, not all of them did and so this change should bring uniformity across all payers.   Practices should pay close attention to coding denials early in 2018 to be sure their billing aligns with the coding each payer will accept as systems are changed over.  Here is the crosswalk of the codes from 2017 to 2018:

 

HCPCS Code for 2017 CPT Code for 2018 Descriptor
G0206 77065

Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral

G0204 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
G0202 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed.


Chest X-rays

 

The reporting of chest x-rays will be defined solely by the number of views taken, so only 4 new codes will be used with 9 codes being deleted, as follows:

 

Description New Code Deleted codes
Single View 71045 71010, 71015
2 Views 71046 71020, 71021, 71022, 71023
3 Views 71047 N/A
4 or more Views 71048 71030, 71034
Special Views N/A 71035


Abdominal X-rays

 

Similarly, abdominal x-rays will be defined by the number of views taken.  Three new codes were created, while 74022 for the Complete Acute Abdomen Series will remain active, as shown below:

Description New Code Deleted codes
Single View 74018 74000
2 Views 74019 74010
3 or more Views 74021 74010, 74020
Complete acute abdomen series 74022 N/A

 

The new codes are not a direct one-for-one replacement of the deleted codes due to the definitions for the old codes.  According to the American College of Radiology, CMS expects that 74019 will be used 25% of the time to replace 74010, while 74021 will be used 75% of the time.

Ultrasound of Extremities

While the coding for theses exams has not changed, the definitions of CPT 76881 and 76882 have been revised and CMS applied a significant valuation reduction to the revised codes. 

 

Whereas 76881 was previously called “Ultrasound Extremity, Complete” it will now become “Ultrasound Complete Joint”.  The complete study code can be used when the examination evaluates the joint space and includes the surrounding soft tissues such as tendons or nerves.

 

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76882 will continue to be a limited exam of the joint, which means that either the joint space or the surrounding tissue was included but not both.  Permanently recorded images are required to be retained under either code, and the written report must clearly describe each of the elements that were evaluated in real time.

 

The CMS revaluation of 76881 was so significant that it is subject to Medicare’s phase-in rule, which limits fee schedule reductions to no more than 19% in the first year.

Nuclear Medicine

Nuclear medicine code 78190 “Kinetics, study of platelet survival” has been eliminated due to low utilization. 

Medicare Billing Modifier

A new modifier ”FY” will be required on Medicare claims for the technical component of diagnostic imaging services that use computed radiography (CR) rather than direct digital image processing, whether billed separately or included in the global billing.  A 7% payment reduction for such services will begin in 2018 and continue through 2022.  The payment reduction will become 10% beginning in 2023.

 

Interventional Radiology

Endovascular Repair Procedures

For 2018 endovascular abdominal aortic aneurysm repair (EVAR) procedures will include radiologic supervision and interpretation (S&I) as an integral part of the procedure code, eliminating the ability to separately bill for the S&I codes.  There are 16 new CPT codes and 4 codes with revised descriptions, while 14 codes were deleted. 

 

New and Revised Endovascular Repair Codes

CPT Code Description

34701   New

Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, penetrating ulcer).

34702    New

Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft, for rupture.

34703

New
Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, penetrating ulcer).

34704

New
Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft, for rupture

34705

New
Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft, for other than rupture (e.g., for aneurysm, pseudoaneurysm, dissection, penetrating ulcer).

34706    New

Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac  endograft, for rupture.

34707

New

Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft, for other than rupture (e.g., for aneurysm, pseudoaneursym, dissection, arteriovenous malformation);

unilateral

34708

New

Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft, for rupture;

unilateral

34709

New

Add-on

Placement of extension prosthesis(es) to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer; per vessel

34710

New

Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration;

initial vessel treated

34711

New
Add-on

each additional vessel treated

34712

New
Transcatheter delivery of enhanced fixation device(s) to the endograft (e.g., anchor, screw, tack)

34713

New

Add-on
Percutaneous access and close of femoral artery for delivery of endograft through a large sheath (12 French or larger); unilateral.  This may be reported once per side.

34812

Revised

Add-on
Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision; unilateral

34714

       New      Add-on

Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision; unilateral

34820

Revised

Add-on
Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision; unilateral

34833

Revised

Add-on
Open iliac artery exposure for creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision; unilateral

34834

Revised

Add-on
Open brachial artery exposure for delivery of endovascular prosthesis; unilateral

34715

New

Add-on
Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by infraclavicular or supraclavicular incision; unilateral

34716

New

Add-on
Open axillary/subclavian artery exposure with creation of conduit for endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision; unilateral

 

Note that the above codes include the following, when performed:

  • all imaging guidance and monitoring;
  • all associated radiological supervision and interpretation;
  • all pre-procedure sizing and device selection;
  • all nonselective catheterization(s);
  • all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation;
  • all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation;
  • temporary aortic and/or iliac balloon occlusion (e.g., for aneurysm, pseudoaneursym, dissection, arteriovenous malformation, traumatic disruption).

Deleted Endovascular Repair Codes

CPT Code Description
34800

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis

34802 using modular bifurcated prosthesis (1 docking limb)
34803 using modular bifurcated prosthesis (2 docking limbs)
34804 using unibody bifurcated prosthesis
34805 using aorto-uniiliac or aorto-unifemoral prosthsesis
34806

Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair

34825

Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel

34826 each additional vessel
34900

Endovascular repair of iliac artery using ilio-iliac tube

endoprosthesis
75952

Radiological S&I for endovascular repair of infrarenal abdominal aortic aneurysm or dissection

75953 Radiological S&I for placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm
75954 Radiological S&I for endovascular repair of iliac artery aneurysm, arteriovenous malformation, or trauma, using ilio-iliac tube endoprosthesis
93982 Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair

 

A complete review of the usage of the revised endovascular repair coding is beyond the scope of this article.  Watch for a separate article that covers the nuances of properly applying these new interventional radiology codes.

Treatment of Pulmonary Tumors

The addition of CPT code 32994 differentiates cryoablation of pulmonary tumors from radiofrequency ablation (CPT 32998), and it replaces Category III code 0340T that was previously used. 

 

Both codes include imaging guidance with the basic procedure, eliminating the ability to separately bill for the guidance codes.  Also note that both are unilateral.

Treatment of Incompetent Veins

Revision of the 3 existing injection codes (36468, 36470 and 36471) makes a distinction between treatment for spider veins (telangiectasia) and for all other diagnoses.  Four new codes were added to report newer methods of treating incompetent veins.  The 2018 codes for these procedures are as follows:

 

CPT Code Description

36465

New

Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate; Single incompetent extremity truncal vein

36466

New
Multiple incompetent extremity truncal veins (same leg)

36468

Revised
Injection of sclerosant for telangiectasia; limb or trunk

36470

Revised

Injection of sclerosant for other than telangiectasia; Single incompetent vein

36471

Revised
Multiple incompetent veins; (same leg)

36482

New

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, percutaneous;

First vein treated

36483

New

Subsequent vein(s) treated in a single extremity, each through separate access sites.

 

The above codes include all imaging guidance and monitoring.

Bone Marrow Procedures

CPT codes 38220 (aspiration only) and 38221 (biopsy by needle or trocar) describing the aspiration of bone marrow have been revised to specify that these are diagnostic procedures.  When a procedure is both an aspiration and a biopsy, new code 38222 is to be used.  Another new add-on code is available, CPT 20939 “Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision” when appropriate.

Brachial Artery Catheter Insertion

Two codes describing the introduction of a needle or intracatheter into an artery have been combined into one code.  CPT 36120 has been eliminated, and 36140 has been revised to include either the retrograde brachial artery or an extremity artery, whether upper or lower extremity.  Angiography brachial retrograde S&I code 75658 has also been eliminated.

Miscellaneous Code Changes

The Category III codes in the table below have been removed or revised as noted:

 

Code Description Comment
0255T

Radiologic S&I for endovascular repair of iliac artery birfurcation using bifurcated endoprosthesis from the  common iliac artery into both the external and internal iliac artery; unilateral

Deleted, refer to code 0254T
0254T Endovascular repair of iliac artery birfurcation using bifurcated endoprosthesis from the  common iliac artery into both the external and internal iliac artery; unilateral Revised to include all radiological S&I
0340T Ablation of pulmonary tumors, including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral Replaced by CPT 32994
0438T Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple New CPT code to be issued
0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time. Will be extended


Conclusion

 

While CMS expects that the impact of all changes to the MPFS will be small for diagnostic and interventional radiology, each practice’s experience will vary based on the volume of procedures that use the affected codes.  A volume-weighted analysis of the entire Medicare fee schedule is recommended to gain a complete understanding of the impact on the practice revenue.  Note that commercial payers might not adopt all of the same coding changes as Medicare does, and it is impossible to summarize here the effect on their payment policies.  This is especially true for non-CPT codes such as the G-codes for mammography.

 

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[i] Current Procedural Terminology is a copyrighted code set developed and maintained by the American Medical Association, and CPT is a registered trademark.


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Topics: MPFS, radiology, interventional radiology, medicare, medicare reimbursement, CPT codes

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