The American Academy of Pain Medicine

Coding News, Tips & Updates

Understanding Fluoroscopy Coding
By Emily Hill, PA

(August 8, 2008)   Basic fluoroscopic guidance codes have been part of CPT since the 1980's.  Since that time, codes have been created for more specific clinical circumstances.  CPT 2007 renumbered and moved certain codes to a new subsection for Fluoroscopic Guidance codes but did not change the descriptors of the codes.   Despite the stability of the service descriptors for fluoroscopic procedures, there remains uncertainly about which specific code to report and when it can be reported.  

Inherent or Separately Reported?

Many radiology codes include in the descriptor "supervision and interpretation".  These codes require that a formal report be completed and that hard-copy images be obtained.  Fluoroscopic guidance is considered an inherent component of many of these services.

For example, fluoroscopy is included in code 72275 (Epidurography, radiological supervision and interpretation) since it is commonly used intermittently during the procedure.  In this instance, parenthetical notes in CPT indicate that fluoroscopy (77003) is included in epidurography.

In other instances, the code descriptor specifically states that guidance is part of the procedure.  This is the case for the codes for percutaneous lysis of epidural adhesions (62263 and 62264) whose descriptors contain the statement "including radiologic localization".

Parenthetical notes also exist for the fluoroscopic guidance codes.  The notes for code 77002 (Fluoroscopic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]) indicate that this service should not be reported separately with any radiographic arthrography except CT and MR arthrography. 

In contrast, other parenthetical notes for 77002 refer the coder to surgical codes for procedure and anatomic location.  Therefore, both the procedure code and the fluoroscopic guidance code can be reported.

Determining Which Fluoroscopy Code To Report

The appropriate code is determined by the specific procedure performed and the documentation in the medical record.  Codes 77002 and 77003 are frequently reported by Pain Medicine physicians.  Determining which code to use is necessary to ensure appropriate reimbursement.

Code 77002 (Fluoroscopic guidance for needle placement [eg, biopsy, aspiration, injection, localization device]) is reported for pain medicine injection procedures when guidance is required to perform the needle placement in areas other than the spine.  It might be reported in addition to codes 64400-64450, 64505-64530, 64600-64620 or 64630-64680.

In contrast, code 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint], including neurolytic agent destruction) is used when guidance is required for spinal or paraspinal injections to direct or localize the needle or catheter tip.  Therefore when guidance is provided in conjunction with codes 64470-64476 and 64479-64484, code 77003 is reported since these codes are used for spinal procedures.

When reporting code 77003, it is important to recognize that it should be reported once per spinal region.  Since the cervical and thoracic regions are two separate regions, code 77003 can be reported once for each region.  Likewise, it can be reported twice when guidance is required for procedures performed in the lumbar and sacral regions. It would not be appropriate, however, to report code 77003 more than once when the guidance is at C7-T1, T12-L1, or L5-S1 junctions.  In these instances, the 77003 is reported only once.

CPT guidelines indicate you should report the most specific code for the service provided.  Therefore when guidance is used in conjunction with pain medicine injection procedures, codes 77002 and 77003 should be reported instead of code 76000 (Fluoroscopy (separate procedure), up to one hour physician time) as they more accurately describe the service rendered. 

  Distinguishing Fluoroscopy Codes from Other Services  

Code 72275 (Epidurography, radiological supervision and interpretation) describes a diagnostic epidurogram and requires hard copy images and a formal report.  It should not be used to report needle localization for epidural injections which is more specifically described by code 77003.  As stated earlier, fluoroscopic guidance is included in epidurography, thus code 77003 should not be reported separately when a diagnostic epidurogram is provided.

Epidurography does not include the placement of the needle or injection of the contrast. These services are reported in addition to code 72275 using the appropriate injection code (62280-62282, 62310-62319, or 64479-64484).

Likewise, code 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation) also requires image documentation and a formal report and does not include the actual injection.  The injection is separately reported using code 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid).  Code 27096 is only reported if imaging guidance is utilized for the injection procedure.  Injections without imaging guidance are reported using code 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa).

When the injection is performed under fluoroscopic guidance but hard copy images and a formal interpretation and report are not provided as required by code 73542, then code 77003 should be reported.  Fluoroscopic guidance (77003) should never be reported in addition to code 73542 since it is an inherent component of the arthrography.

Although there may seem to be a number of options and coding combinations, CPT instructions provide specific direction for reporting guidance services with other procedures.   Being familiar with these instructions and the appropriate code combinations helps ensure appropriate reimbursement and protects against audit liability.