The CPT Code
Current Procedural Terminology (CPT) is
a nationally standardized set of codes used to bill procedures
and services to Medicare and nearly all third-party payers. The
CPT system includes a comprehensive list of codes for surgical
and medical procedures, as well as codes for consultations and
diagnostic tests.
CPT codes are the language of reimbursable medical services.
Hospital outpatient departments and freestanding imaging centers
must use them to bill for professional and technical services.
Each CPT code is associated with a certain number of Relative
Value Units (RVUs) based on the amount of work, expenses, and malpractice
risks associated with the procedure. The RVUs, adjusted for cost
of living, determine what Medicare reimburses for that CPT code
in a particular locality.
The Medicare reimbursement is used as a reference point
for other payers’ reimbursement. Thus, the CPT code for a
procedure and its corresponding RVU-based reimbursement has a tremendous
impact on what healthcare providers will be paid for the procedure.
Reimbursement for most radiology codes is divided into
two categories: technical and professional. Technical reimbursement
covers the cost of the scan. Professional reimbursement covers
the interpretation of the scan.
Reimbursement in Radiology
To be reimbursable, a procedure must have a CPT code.
With certain exceptions, the procedure must be ordered
by a clinician or surgeon
The procedure must be indicated: the patient must have
a symptom from a pre-approved list devised by Medicare. The symptoms
are taken from the ICD-9 codes, an international standard for coding
patient symptoms.
The procedure must be documented appropriately by the
radiologist in the report.
Coding and Billing for CT Colonography
The goal of CTC coding is to determine whether, in a given case,
insurance or the patient should pay for the exam. CTC does have a
CPTcode. Therefore, it is billable only if another CPT code is appropriate.
Typically, the codes for a CT of the abdomen and pelvis with 3D reconstruction
are used for diagnostic colonography. The usual determinant is whether
the patient has appropriate symptoms.
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