Coding Q&A By Julie C. Bulman, MD, RPVI Coding guidance for T
his updated guidance, developed in collaboration with the Society of Interventional Radiology, the American College of Radiology and the Society of Nuclear Medicine & Molecular Imaging, expands on planar imaging and SPECT CT codes for nuclear medicine imaging during the mapping process and when to use CPT® codes 78801, 78830–78832, or 78835. During the mapping process, if a limited CT is medically necessary to evaluate the pre- embolization arterial phases, then CPT® 76380 may be appropriate to bill. When calculating the amount of Y-90 to be administered, it is reportable with code 77300, which requires documentation, including using patient-specific data to determine the total amount for administration. If a PET/CT were ordered and performed, the “limited” code would be appropriate (due to the specific area related to the Y-90 administration) and billable with code 78814. Additionally, when a measure is generated from SPECT or planar data, there is no current code for this work. The most appropriate code would be unlisted CPT® 78999 for this measurement.
Selective internal radiation therapy (SIRT) with Y-90 Selective internal radiation therapy (SIRT) is a minimally invasive procedure in which a trained physician inserts a microcatheter into the hepatic artery to administer microspheres of Y-90 to treat hepatic tumor(s) with radiation. To determine if the patient is an appropriate candidate for a therapeutic dose of Y-90, a mapping session is first conducted to evaluate the amount of the radiopharmaceutical technetium- 99m macroaggregated albumin (Tc99m-MAA) that is delivered to the intended target or volume of interest in the liver versus the amount that shunts to the lungs and other nearby organs. If the results of the mapping session do not exceed threshold for the amount of
nuclear medicine imaging Selective internal radiation therapy (SIRT)with Y-90
Tc99m-MAA which shunts to the lungs, then the physician will move forward with orders for SIRT with Y-90, including the potential for pre and/or post- administration dosimetry.
Coding for mapping Diagnostic angiography is performed once optimal vascular access has been determined. All selective catheter placements and diagnostic imaging for this first session are separately reportable with the appropriate selective catheterization codes (36245–36248) and associated RS&I codes (75726 and 75774), if appropriate. Additionally, if a limited CT is medically necessary and performed during the mapping procedure (such as to evaluate pre-embolization arterial phases of the hepatic artery), then code 76380 may be assigned.
Embolization of non-target vessels to prevent administration of radioactivity to non-target vascular beds is reportable using code 37242. Note that embolization in this setting is considered to take place in one “operative field,” so even when more than one vessel is embolized, only a single embolization code is reported. Also note that angiography and CT imaging performed during and following the embolization are included services within the embolization code and is not separately reportable, as addressed in CPT Assistant, March 2019.
The intra-arterial injection of Tc99m-MAA (HCPCS A9540) during the mapping procedure and subsequent nuclear medicine imaging is reportable using code 78803, 78830, 78831 or 78832, depending on whether a SPECT/CT or SPECT was performed and the number of areas imaged, according to the definition of each code. If only planar imaging is performed, this is typically billed with code 78801. Note that radiopharmaceutical localization codes
are reported by the individual responsible for the supervision and interpretation of the Tc99m-MAA exam, which may be a separate individual than the IR physician, depending on practice arrangements.
Following Tc99m-MAA imaging, calculation of extrahepatic shunt fraction is performed using the SPECT/CT, SPECT or planar data by measuring the amount of radiotracer that has traveled to the lungs or other areas of the body. When the measurement is generated from SPECT/CT data, this is reportable with code 78835 and may be reported multiple times if more than one area is measured. When the measurement is generated from SPECT or planar data, there is no specific code for this, so an unlisted code (78999) may be reported for this work. Regardless of which imaging and measurement modality is utilized, documentation of the calculated shunting values is required.
Coding for radiation clinical treatment planning The clinical treatment planning process generally includes interpretation of available advanced imaging studies, tumor localization, treatment volume determination, treatment time and dosage determination, choice of treatment modality, and selection of appropriate treatment devices. Institutions licensed to administer Y-90 must have an authorized user (AU) who is responsible for the pre- procedure dosimetry and treatment planning. SIRT is a brachytherapy procedure and guidance from payors supports billing the associated clinical treatment planning by the physician at the complex level with 77263, but the documentation must appropriately meet the requirements for a complex treatment plan. Specifically, in generating the plan, the AU should utilize the following data, when available, in determining the
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