3 Can’t-Miss Reasons to Read the Radiology CPT® Coding Guidelines

CPT guidelines for radiology coding

Supervision and interpretation, contrast, and images — these are all terms you need to know for radiology CPT® coding. The 70000 Radiology section guidelines are a good place to start for authoritative information.

Helpful: If you use a paper CPT® manual, you are likely to find the Radiology section guidelines directly preceding the first 70000 section code. If you use a TCI SuperCoder online coding package, you’ll find a Radiology Guidelines link on the details page for each code in the 70000 section.

Now let’s look at what you’ve been missing if you haven’t read the guidelines for yourself.

1. Are You Clear About RS&I?

Many code descriptors in the Radiology section include the phrase “radiological supervision and interpretation.” You may see this abbreviated as RS&I or S&I.

The Radiology section guidelines explain that when a code for a procedure does not include imaging, then you may report an RS&I code for the part of the service that requires imaging.

Documentation: The guidelines go on to explain that all RS&I codes require these two things:

  • image documentation in the patient’s permanent record
  • written documentation in either a procedure report or a separate imaging report with interpretive findings based on the images and radiological supervision performed.

2. When Is Contrast Not Contrast?

One of the challenges of coding is that terms that appear clear in descriptors may have a different meaning when you dig deeper.

In radiology coding, you’ll want to keep that truth in mind before you select a code that includes “with contrast” in the descriptor.

Here’s why: You’ll find the term “with contrast” in code descriptors for procedures that use contrast material for imaging enhancement. The area to watch is that “with contrast” applies only if administration is intravascular, intra-articular, or intrathecal.

Oral and/or rectal contrast does not qualify as “with contrast” for radiology CPT® coding.

Tip: There are more 70000 section guidelines about coding contrast, so read the whole set to ensure you’re coding properly. You’ll find instructions for arthrography and spine exams in particular.

3. How Does ‘Electronic’ Factor In?

Handwritten reports and film images haven’t been your only option in radiology for a long time. The guidelines factor this in by explaining that the “written” report that is integral to radiologic procedures and interpretations can be either handwritten or electronic.

Similarly, “images” for these services may be either analog (film) or digital (electronic). And as a bonus tip, CPT® states that for imaging services, images must have “anatomic information unique to the patient.”

What About You?

Do you take the time to read CPT® section guidelines relevant to the code sections you use? What’s the most useful information you’ve found there?

 

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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