Neurosurgery Coding Alert

Hint: Check the documentation for the exact approach.

If your neurosurgeon performs myelography in your practice, you know how important it is to check for numerous details in the documentation such as the approach he used and whether he performed a follow- up X-ray/CT imaging or not.

“While MRI has substantially replaced myelography as a modality for imaging spinal conditions, there are a number of circumstances (such as a patient with an MRI-incompatible pacemaker) in which myelography with follow-up CT imaging can provide information about processes outside of the spinal cord but inside the spinal canal similar to that obtained by MRI,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Read on to learn more.

Tip 1: First, Understand Myelography for Clarity

When your neurosurgeon performs a myelogram, the purpose of the imaging is to identify abnormalities within the subarachnoid space of the spine. Your neurosurgeon will visualize the area between the spinal cord and the vertebrae by using a contrast dye injection via fluoroscopic guidance. Physicians may also perform radiographic imaging such as X-rays and Computed Tomography (CT) scans alongside to supplement this procedure.

“An X-ray myelogram provides imaging of the entire region of the spine on a single image,” per according to CPT^® Assistant Vol. 24, No. 9. “In some cases, various special techniques may be used during the procedure, such as gravity via a tilt table, natural weight bearing, lateral bending, flexion, and hyperextension to detect lateral recess nerve root compression and spinal stenosis.”

Tip 2: Myelography Approach Via C-1-C2 or Posterior Fossa? Do This

You will choose the correct myelography code depending upon where your surgeon administered the injection. If your neurosurgeon performs a cervical, thoracic, or lumbar myelography via the C1-C2 or posterior fossa, you should report the following codes:

• Report 61055 (Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment) for the injection only. Note: You should never report code 61055 in conjunction with codes 62302-62305, according to CPT^®.
• Report 72240 (Myelography, cervical, radiological supervision and interpretation) for imaging only.
• Report 72255 (Myelography, thoracic, radiological supervision and interpretation) for imaging only.
• Report 72265 (Myelography, lumbosacral, radiological supervision and interpretation) for imaging only.
• Report 72270 (Myelography, 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation) for imaging only.

Don’t miss: You should never report codes 72240, 72255, 72265, and 72270 in conjunction with codes 62284 and 62302-62305, per CPT^®.

Don’t miss: If you neurosurgeon performs the myelography via the C1-C2 or posterior fossa route, CPT^® does not offer you a combo code that includes both imaging and radiological supervision and interpretation. So, if your neurosurgeon performs both, you should report both the imaging and radiological supervision and interpretation codes (61055, 72240/72255/72265/72270). However, you should not report a fluoroscopic guidance code in addition to these two.

“There are two typical routes for introducing a myelographic contrast medium: C1-C2 or lumbar puncture,” Przybylski says. “The former is infrequently done, likely related to the higher risk of spinal cord injury when compared with lumbar puncture, which is typically performed below the bottom of the spinal cord, termed the conus.”

While CPT^® combines the injection procedure with the supervision and interpretation (S&I) services for myelography performed after lumbar puncture, the injection at C1-C2 does not include supervision and interpretation of the imaging, Przybylski adds. This is likely related to the fact that the C1-C2 injection may be performed by a different professional than the S&I services.

“Whereas, radiologists perform fewer than half of the C1-C2 punctures, they perform more than 95 percent of lumbar myelograms with imaging of at least two spine regions,” Przybylski says. “By separating the injection from the S&I services in C1-C2 puncture for myelography, CPT^® allows professionals of different backgrounds to report their individual work when the same professional does not perform both services, as occurs most of the time.

Tip 3: Pinpoint These Codes for Lumbar Injection

On the other hand, if your neurosurgeon administers the injection into the lumbar area of the patient’s spine and performs the myelography at the cervical, thoracic, and lumbosacral regions, you will turn to the following codes:

• 62284 (Injection procedure for myelography and/or computed tomography, lumbar) Note: Code 62284 is used to describe the needle placement via the lumbar approach into the thecal sac and contrast medium injection for myelography, according to CPT^® Assistant.
• 62302 (Myelography via lumbar injection, including radiological supervision and interpretation; cervical)
• 62303 (Myelography via lumbar injection, including radiological supervision and interpretation; thoracic)
• 62304 (Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral)
• 62305 (Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/ cervical, lumbar/thoracic/cervical)

Tip 4: Pay Attention if Follow-Up X-Ray CT Was Performed