General Surgery Coding Alert

Although 76000 and 76003 are nonspecific, they differ greatly, says Kathleen Mueller, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. "You use 76003 for localizations, biopsies and other services involving needle placement when fluoroscopy is used," she says. "In some cases, surgeons may use fluoroscopy instead of ultrasound."

Note: Ultrasonic guidance for needle placement is coded 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). General fluoroscopy (76003) often is performed for guidance instead of ultrasound.

Code 76000 is generic and should be used only when no specific fluoroscopy code describes the procedure. "For example," Mueller says, "if the removal of a foreign body is performed under fluoroscopic guidance, 76000 would be the appropriate code because there is no specific code that describes this service."

Another important example involves the placement of a central venous catheter. This procedure, which is coded 36489 or 36533 depending on whether the catheter is "tunnelled" under the skin, often is performed under fluoroscopic guidance, but CPT does not include a specific fluoroscopy code for the service.

CPT instructs surgeons who use imaging guidance with 36489 to report 76000, notes Linda Laghab, CPC, coding manager for Pediatric Management Group at Children's Hospital Los Angeles. "When reporting 76000, the surgeon need not dictate a separate radiology report. Instead, the use of fluoroscopy may be documented by including a sentence similar to the following: 'Under fluoroscopic guidance, the catheter was inserted, and the tip of the catheter is in good position,' " she says.

Until recently, Medicare had not issued any policies or instructions regarding the bundling of 76000 into vascular procedures. Version 7.3 of the Correct Coding Initiative (CCI), which became effective Oct. 1, 2001, however, included new guidelines that would restrict separate payment to only those nonroutine catheter placement or endoscopy procedures.

According to Chapter 1 of the CCI, "placement of central access devices (central lines, pulmonary artery (PA) catheters, etc.) involves passage of catheters through central vessels and, in the case of PA catheters, through the right ventricle; additionally, these services often require the use of fluoroscopic support. Separate reporting of CPT codes for right heart catheterization, first order venous catheter placement or other services which represent a separate procedure, is not appropriate when the CPT code that describes the access service is reported. General fluoroscopic services necessary to accomplish routine central vascular access or endoscopy cannot be separately reported unless a specific CPT code has been defined for this service" (emphasis added).

Consequently, fluoroscopic guidance should be reported separately using 76000 only when the placement is unusual, Mueller says. "The inclusion of the word 'routine' adds up to this: If you always do a procedure with fluoroscopy and it cannot be done without it, 76000 is not payable separately. If, however, the surgeon normally performs the procedure without fluoroscopy but is required to use it for a specific reason, 76000 may be reported."

Some coding specialists recommend using 76003 in place of 76000 for fluoroscopic guidance for routine central venous catheter (CVC) placements. They note that 76003 is one of three codes 76000 and 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) are the others that CPT specifically directs physicians to use when performing 36489 or 36533.

Mueller disagrees: "The guideline in the CCI doesn't mention a specific code. It says, 'general fluoroscopic services,' which could apply to 76000, 76003 or any other fluoroscopic service." She recommends using 76000 or 76003, as appropriate, only for nonroutine CVC placements involving fluoroscopy.

Note: If the surgeon or his practice does not own the fluoroscopy equipment, modifier -26 (Professional component) should be appended to 76000 and 76003 claims, as appropriate.

Many surgeons and coders incorrectly believe that because 76000 is a separate procedure, it can never be billed unless it is performed on its own. This is not exactly true, Mueller says.

"In the case of 76000, the 'separate procedure' designation applies only to other radiology procedures, not to surgical procedures. You are supposed to report 76000 with surgical procedures when it is appropriate," she says.

The "separate procedure" designation is significant, however, if other radiology procedures are performed. For example, during the course of a cholecystectomy, the physician often performs a cholangiogram to image the biliary tree for anatomy and the presence of possible common bile duct stones and to ensure the free flow of contrast into the duodenum to preclude obstruction of the common bile duct.

Fluoroscopic guidance always is required to perform the cholangiogram and, therefore, 76000 would not be billed in addition to the procedure because it cannot be performed without fluoroscopy. However, 74300, which describes supervision and interpretation of cholangiography, may be reported if there is a separate dictated radiology report and a radiologist is not present during the procedure.

The same applies to angioplasties or other peripheral/ vascular interventions. The angiography that is performed to image the vessel being treated also requires fluoroscopic guidance. But the appropriate radiology supervision and interpretation (S&I) code for the intervention performed includes the fluoroscopic guidance because 76000 is a separate procedure and also because the percutaneous transluminal angioplasty (PTA), like the cholangiogram discussed previously, always uses fluoroscopic guidance.

Note: To report S&I for the cholangiogram, PTA or another radiology service, you must document a separate radiology report. Further, surgeon-radiologist relations may play an important role in determining who bills these separately reported S&Is. This is not the case with 76000 or 76003, which do not require a separate report.