Published 1/1/2016
Mary LeGrand, RN, MA, CCS-P, CPC

Category 1 CPT Coding Update 2016: Imaging Services

Changes made in the radiology section of Current Procedure Terminology (CPT) coding in 2016 may have an impact on orthopaedic practices, particularly with respect to the possibility of audits. Orthopaedists who submit billing and reporting for imaging services must meet the same standards as radiologists, including a comprehensive report.

Twelve new CPT codes were added and several other changes were made to the radiology section (Table 1). In addition, the reporting requirements for radiology services were clarified and stressed.

Imaging guidance
According to the 2016 CPT Manual, Professional Edition (page 68), "When imaging guidance or imaging supervision and interpretation is included in a surgical procedure, guidelines for image documentation and report included in the guidelines for radiology (including nuclear medicine and diagnostic ultrasound) will apply."

The 2016 guideline revised the written report(s) section for radiology notes. The guidelines emphasize that a handwritten or electronic report signed by the interpreting individual, is an integral part of a radiologic procedure or interpretation. It further defines images as those acquired in either an analog (film) or digital (electronic) manner.

Radiology supervision and interpretation
Frequently, imaging is required during the performance of certain procedures. In addition, certain imaging procedures may require surgical procedures to access the imaged area. In these situations, imaging is considered part of the procedure and is not separately reportable.

According to CPT rules, when image guidance or imaging supervision and interpretation is included in a surgical procedure, orthopaedic surgeons should follow the guidelines for image documentation and reporting from the Radiology section of CPT.

The need for separate reports for imaging services has been covered in previous AAOS Now articles and at AAOS-sponsored coding and reimbursement workshops. Links to these articles can be found at the end of this article.

Medicare documentation
According to Diagnostic Radiology (November 2008), Medicare expects a separate and distinct report of diagnostic radiographs that follows the American College of Radiology (ACR) guidelines. The report may be on separate paper or within the body of the patient's record. At a minimum, the following information must be included:

  • The name of the patient and other identification such as birth date and Social Security number
  • The name of referring physician, if any
  • The name or type of examination performed
  • The date on which the radiograph was performed
  • The name of the interpreting physician
  • Authentication of notes not written by hand (ie, legible initials, legible signature, electronic signature)
  • The body of the report must include the procedures and materials, findings, limitations, clinical issues, and comparative data, if indicated.
  • When possible, a prescribing diagnosis should be appropriate; when appropriate, a differential diagnosis should be provided.

Diagnostic or therapeutic nerve blocks
Three new codes (Table 2) appear in the Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic section of CPT for paravertebral blocks via single injection or continuous infusion. These codes include a parent or index code (64461), an add-on code (64462), and an indented code (64463). They are listed in the manual as new and have a hashtag (#) symbol indicating they are out of numerical sequence.

CPT code 64412—Injection, anesthetic agent; spinal accessory nerve—was deleted in 2016. Instead, orthopaedic surgeons should report 64999—Unlisted procedure, nervous system—for an injection of an anesthetic agent into a spinal accessory nerve.

Action Steps

  • Orthopaedic surgeons who dictate radiographic interpretations in the body of their clinical note should request that the transcriptionist copy and paste the interpretation in the reports page under the Radiology tab. The interpretation must include specific views, anatomic location, diagnosis, reason for radiograph, and interpretation.
  • Orthopaedic surgeons who use an electronic health record (EHR) should work with the EHR vendor to create a section within evaluation and management (E/M) for a radiographic interpretation within the body of the E/M note and an electronic hyperlink to a separate report in the Radiology section.
  • All information related to the ordering of radiographs, anatomic views, location, and interpretation must be within the body of the E/M note to receive "credit" for the medical decision making. Some payers will not allow credit if just global radiology codes are reported.
  • Both the E/M note and the separate interpretation should be signed by the surgeon. If an electronic signature is used, the surgeon must create it; this task cannot be delegated to staff!
  • Charge capture tools (EHR, practice management systems, and paper) must be updated to support the new codes; the old codes should be deleted.
  • Check the 2016 CPT Manual for information on E/M codes 99415 and 99416 (prolonged services by clinical staff with direct supervision by the physician).
  • Check coding resources for changes in HCPCS Level II and Level III codes. Remember, Medicare does not recognize HCPCS Level III codes.

Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc. Information on this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee.

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