Anesthesia Coding Alert

Question: Our physician administered a caudal epidural injection, then a left sacroiliac (SI) joint injection. He used fluoroscopic guidance for both injections. How many times can I bill the fluoroscopy?


Michigan Subscriber

Answer: You can only report one fluoroscopy code per session, regardless of how many levels your physician injects for the patient.

Code the caudal epidural injection with 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) and the SI injection with 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) with modifier LT (Left side). Append modifier 51 (Multiple procedures) to 27096 to indicate separate services.

Report 76005 (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) for the fluoroscopic guidance.

Equipment note: If your physician does not own the fluoroscopy equipment he uses during the procedure, append modifier 26 (Professional component) to show he performed the service. If your physician owns the equipment, performs the service and interprets the results, do not include modifier 26.