Do you know how to bill CT scans of the abdomen and pelvic area that require imaging with and without contrast? You might think to simply bill them separately using the distinct codes. But no, doing this will result in denials.
Such comprehensive CT scanning is billed with CPT code 74178. However, many billers don’t know how to use this code properly. That’s why our billing experts at MediBillMD have created this detailed guide on 74178. So, let’s get right into it.
CPT Code 74178 – Description
The official descriptor of CPT code 74178 defines it as:
Computed Tomography (CT), abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions.
The definition might confuse you, so let’s break this down into simpler terms.
Code 74178 is used for a CT scan of the abdomen and pelvis region. What makes 74178 different from other pelvic and abdominal imaging codes is the sequence of procedures. Unlike other codes, 74178 includes imaging both with and without contrast. The procedure begins with non-contrast imaging and progresses to contrast-enhanced imaging during the same imaging session.
The entire procedure takes about 30-60 minutes. Additionally, before the CT scan, the patient needs to be properly prepared. The physician might ask the patient to fast before the scan and also order blood tests to check the kidney function. This is done to minimize the risk of any complications induced by the contrast dye.
An important thing to note here is that in most cases, you can only use one unit of 74178 per day. However, in some rare cases, the procedure might be repeated the same day. In this situation, the correct way of claim submission is to append modifier 59 or XE to the second instance.
Scenarios Where CPT Code 74178 is Applicable
To make things clear, let’s look at a couple of real-world scenarios in which CPT code 74178 can be used.
Amebic Liver Abscess
Let’s consider a 45-year-old construction worker who recently returned from a business trip to Southeast Asia. However, since his trip, he has been experiencing severe right upper quadrant pain, high fever, and profuse sweating. He tried many home remedies and over-the-counter medicines, but the pain worsened. He also feels nauseated, and his appetite has completely disappeared. Initial blood work reveals an elevated white blood cell count and liver enzymes.
Given the patient’s travel history and symptoms, the physician suspects a hepatic abscess. To confirm the diagnosis, the physician orders a CT scan of the abdomen first without contrast, followed by contrast-enhanced imaging. The results show a large pus-filled lesion in the liver. This confirms a case of amebic liver abscess. The imaging can be billed with CPT code 74178 in this scenario.
Tuberculosis of the Spine
Let’s now consider another example of a tuberculosis (TB) patient.
Suppose a 50-year-old patient visits his physician. He complains of persistent lower back pain. The pain started mildly but has worsened over the weeks. The pain is accompanied by evening fevers, weight loss, and difficulty walking. Upon some inquiry, he tells the physician that he was recently treated for pulmonary TB.
Concerned about spinal TB involvement, the physician orders a CT scan of the abdomen and pelvis to evaluate the lumbar spine. The scan is performed both with and without contrast. The result reveals vertebral destruction and paravertebral masses consistent with spinal tuberculosis. This CT examination can be coded with CPT code 74178.
Applicable Modifiers for CPT Code 74178
The following are some modifiers that you can append to CPT code 74178 claims:
| Modifier | Description | Usage |
|---|---|---|
| 26 | Professional Component | Used when billing only for the physician’s interpretation and report. |
| 52 | Reduced Services | Used when the procedure is partially reduced or eliminated at the physician’s discretion, reflecting decreased complexity or scope of service. |
| 53 | Discontinued Procedure | Applied when the procedure is started, but discontinued due to extenuating circumstances, risking the patient’s health. |
| 59 | Distinct Procedural Service | Indicates that the procedure is distinct and separate from other services performed on the same day. |
| CT | Equipment Non-compliance | 15% payment reduction. Used when equipment used to furnish certain services does not meet attributes of the National Electrical Manufacturers Association (NEMA) Standard XR–29–2013 |
| TC | Technical Component | Applied when billing only for the technical aspects, including equipment, supplies, and the technician’s services. |
| XE | Separate Encounter | Indicates that the service is distinct and separately reimbursable because it was performed during a separate encounter on the same service date. |
CPT Code 74178 – Billing & Reimbursement Guidelines
Insurance payers need a single reason to deny your claim. Therefore, don’t give them any opportunity! The following are some vital points that you must consider while filing claims for CPT code 74178:
Comprehensive Documentation
Documentation is essential to prove the medical necessity of the procedure. Record the following details in the patient’s medical records:
- Patient’s name
- Date of service
- Written request from the physician who ordered the CT scan
- Notes explaining why the patient needs the scan
- Official results written by the radiologist
- Proper signatures from qualified medical staff
- List of symptoms
Check the Medicare Reimbursement Rate
The national average reimbursement amount for 74178 is $332.85 in non-facility settings.
The following is a more detailed breakdown of the cost structure:
1. Professional component:
- Facility price: $91.54
- Non-facility price: $91.54
2. Technical component:
- Facility price: Not applicable
- Non-facility price: $241.30
You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool.
Confirm Prior Authorization Requirements
Prior authorization issues are one of the most common reasons for claim denials. Many private insurance companies, such as AvMed and Blue Cross and Blue Shield of Texas, require prior authorization for CPT code 74178. However, Medicare does not have this requirement.
Always ensure to check the authorization requirements before submitting the claim.
Wrapping Up
In this blog, we tried our best to simplify CPT code 74178 for you. Let’s do a quick recap.
Code 74178 refers to a CT scan of the abdomen and pelvic area. It includes scanning both with and without a contrast dye. Always make sure to append the appropriate modifiers (when necessary) and get pre-authorization (if required by the payer) before submitting the claim.
However, if you experience frequent denials, you can always seek help from professional billing companies. Reputable companies like MediBillMD offer expert radiology billing services at competitive rates.
