By Rebecca Farrington, AuntMinnie.com contributing writer

January 15, 2019 -- Each year, there are revisions of current procedural terminology (CPT) codes that will affect the way radiology practices code their procedures and, ultimately, how they are reimbursed for those procedures. The majority of CPT code changes in radiology for 2019 are for interventional radiology procedures. Those that pertain to diagnostic radiology are in ultrasound, MRI, and nuclear medicine. We'll cover the diagnostic codes first and then go into detail about the interventional coding changes.

Diagnostic radiology

MRI

The coding for breast MRI has been changed by the deletion of two codes and their expansion into four new codes, as shown below.

Coding for breast MRI
Description New code Deleted code
MRI breast, without contrast, unilateral 77046 77058
MRI breast, without contrast, bilateral 77047 77059
MRI breast, without and with contrast, unilateral 77048 77058
MRI breast, without and with contrast, bilateral 77049 77059

The new series of codes provides for the distinct billing of noncontrast exams, which previously had to be billed using the with/without contrast codes. Note that 77048 and 77049 also include computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis) when performed. This bundling eliminates the separate use of Healthcare Common Procedure Coding System (HCPCS) code 0159T that was previously added when performing CAD.

Another new MRI code, 76391, has been issued for MR elastography.

Ultrasound

There are two areas of change in ultrasound, with new codes added for targeted dynamic microbubble sonographic contrast characterization and for elastography.

Coding for ultrasound
CPT code Description
76978 (new) Targeted dynamic microbubble sonographic contrast characterization (noncardiac); initial lesion
76979 (new add-on) Each additional lesion with separate injection
76981 (new) Elastography, parenchyma (e.g., organ)
76982 (new) Elastography; first target lesion
76983 (new add-on) Each additional target lesion, not to be used more than two times per organ

When evaluating a parenchymal organ and lesion(s) in the same parenchymal organ at the same session, only 76981 is to be reported, and it is to be reported only once per session for evaluation of the same parenchymal organ. Shear-wave liver elastography without imaging is to be reported using CPT 91200. These new codes eliminate HCPCS code 0346T that was previously used for ultrasound elastography in addition to another primary procedure.

Nuclear medicine

Three nuclear medicine codes (78270, 78271, and 78272) related to vitamin B12 absorption studies have been eliminated.

Other diagnostic radiology

CPT 76001 for more than one hour of fluoroscopy time has been eliminated, leaving CPT 76000 as the only choice for fluoroscopy time reporting.

The code 27370 for injection of contrast during knee arthrography has been deleted and replaced by 27369, "Injection procedure for contrast knee arthrography or contrast-enhanced CT/MRI knee arthrography."

Interventional radiology

Central venous access

The coding for peripherally inserted central venous catheters (PICC) has been expanded with new codes that include imaging guidance when it is used and revision of the existing codes to specify that no imaging guidance was used.

New and revised PICC coding
CPT code Description
36568 (revised) Insertion of a PICC, without subcutaneous port or pump, without imaging guidance; younger than 5 years of age
36569 (revised) Age 5 years or older
36572 (new) Insertion of a PICC, without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation; younger than 5 years of age
36573 (new) Age 5 years or older
36584 (revised) Complete replacement of a PICC, without subcutaneous port or pump, through the same venous access, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation

With the changes described above, it is no longer appropriate to use CPT 76937 or 77001 for ultrasound or fluoroscopic imaging guidance in addition to these procedures. Similarly, these codes include any imaging to document the final catheter positioning, so the billing of a separate chest x-ray (71045, 71046, 71047, or 71048) will not be allowed on the same date as the PICC insertion or replacement. When the final positioning is not confirmed, the PICC procedure should have modifier -52 added to indicate the limited scope of the procedure.

Fine-needle aspiration (FNA)

Beginning in 2019, FNA biopsy procedures will be bundled to include imaging guidance when performed under ultrasound, fluoroscopy, CT, or MRI. Accordingly, a new series of CPT codes will be used for these procedures to replace the combination of old code 10022 (FNA with imaging guidance) and a separate imaging modality guidance code.

New and revised fine-needle aspiration biopsy coding
CPT code Description
10021 (revised) FNA biopsy without imaging guidance; first lesion
10004 (new add-on) Each additional lesion
10005 (new) FNA biopsy, including ultrasound guidance; first lesion
10006 (new add-on) Each additional lesion
10007 (new) FNA biopsy, including fluoroscopic guidance; first lesion
10008 (new add-on) Each additional lesion
10009 (new) FNA biopsy, including CT guidance; first lesion
10010 (new add-on) Each additional lesion
10011 (new) FNA biopsy, including MRI guidance; first lesion
10012 (new add-on) Each additional lesion

Renal pelvic catheter procedures

In a similar fashion, renal pelvic catheter procedures will now be bundled to include all imaging guidance and radiological supervision and interpretation in a single code. Accordingly, CPT 50395 (introduction of guide into renal pelvis and/or ureters with dilation to establish nephrostomy tract) has been deleted and replaced by the coding in the table below.

New and revised renal pelvic catheter coding
CPT code Description
50436 (new) Percutaneous dilation of existing tract for an endourologic procedure
50437 (new) Percutaneous dilation of existing tract for an endourologic procedure, including new access into the renal collection system
74485 (revised) Dilation of ureter(s) or urethra, radiological supervision and interpretation; this code is no longer used for nephrostomy

Note that both of the new codes (50436 and 50437) now include all imaging guidance, and all associated radiological supervision and interpretation, as well as postprocedure tube placement when it is performed. Revised code 74485 should be reported to interpret pre- and postdilation imaging, making note of the response to treatment, potential complications, and fluoroscopy time used. Retrograde percutaneous nephrostomy continues to be reported using code 52334 without any change.

Gastrostomy

The coding for the percutaneous change of a gastrostomy tube has been expanded. CPT 43760 (percutaneous change of gastrostomy tube, without imaging or endoscopic guidance) has been deleted and replaced, as indicated below.

New gastrostomy tube change coding
CPT code Description
43762 (new) Percutaneous change of gastrostomy tube, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract
43763 (new) Requiring revision of gastrostomy tract

Percutaneous replacement of a gastrostomy tube under fluoroscopic guidance continues to be reported using CPT 49450 without any change.

Conclusion

The bundling of imaging guidance and the supervision and interpretation of the exam into a single code for the entire procedure continues to be the major theme of these revisions. We will separately analyze the financial impact of these changes in an upcoming article, even though Medicare has reported that the overall effect of the 2019 Medicare Physician Fee Schedule on radiology practices will be minimal. Each practice has to evaluate any fee schedule changes in light of its mix of modalities and procedure volume.

Rebecca Farrington serves as the chief revenue officer for Healthcare Administrative Partners. She has more than 20 years of experience in healthcare sales and management roles, focusing on hospital-based and physician revenue cycle management.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.


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