Anesthesia Coding Alert

Question: Does a physician have to write a separate report for an epidurogram?

South Carolina Subscriber

Answer: The key word here is "separate." A physician has to provide a detailed description of the interpretive study of the dye to bill 72275 (epidurography, radiological supervision and interpretation), which is used to report an interpretive report of the results of the injection of dye into the epidural space.

Simply writing "patient placed in prone position under fluoroscopic guidance" is insufficient, and merits only the basic fluoroscopy code (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).

However, the detailed description can be part of the overall procedure notes. It is probably preferable to include the radiology report in a separate section of the procedure notes, but a separate report is unnecessary.
 

Note: If the physician does not own the equipment, modifier -26 (professional component) should be attached to 72275 to indicate that professional services are only being billed.