Neurosurgery Coding Alert

Work out these real-world coding scenarios to master myelographies once and for all.

Last month, you were taught all you need to know to effectively code your physician's myelography procedures, if and when the situation arises. While the information provided offered you a solid foundation on myelography coding, it didn't fully prepare you to handle a myelography coding scenario in real-time.

That's because instructional learning without corresponding examples can only take you so far. Here, you're going find out all you need to know on how to code two situations you may happen to find yourself in.

Take a look at these two examples to fill in the final piece of the myelography coding puzzle (and be sure to use last month's article as a reference guide!).

Differentiate Fluoroscopic Spot Film from Radiographic Imaging

Example:
After informed oral and written consent was obtained and a timeout was performed, fluoroscopy was used to evaluate the lumbar spine. The right L4-L5 interlaminar space was identified. The overlying skin was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the skin and subcutaneous tissues. Then, a 22-gauge spinal needle was advanced under intermittent fluoroscopic guidance into the thecal sac. Clear CSF was noted in the needle hub. Then, 8 ml of omnipaque-240 IV contrast was injected into the thecal sac and a fluoroscopic spot film was obtained. Upright imaging was obtained of the L2-L3 column. No instability is identified.

The correct codes in this scenario are 62284 (Injection procedure for myelography and/or computed tomography, lumbar) and 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure)).

"Remember that fluoroscopic guidance with a spot film is not equivalent to radiographic imaging," explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. In this example, the physician does not document any radiographic imaging. The documentation of "upright imaging" without elaboration to an X-ray or computed tomography (CT) scan should not be considered equivalent to radiographic imaging. Since this dictation does not warrant the inclusion of imaging, the all-encompassing code 62304 (Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral) is not applicable here.

Instead, you'll opt to include 62284 to document the injection and 77003 to document the use of fluoroscopic imaging. Next, let's look at an example where radiographic imaging is included with the myelography.

Look for Documentation of X-ray in Body of Report

Example:
After informed oral and written consent was obtained and a timeout was performed, fluoroscopy was used to evaluate the lumbar spine. The right L4-L5 interlaminar space was identified. The overlying skin was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the skin and subcutaneous tissues. Then, a 22-gauge spinal needle was advanced under intermittent fluoroscopic guidance into the thecal sac. Clear CSF was noted in the needle hub. 8 ml of omnipaque-240 IV contrast was injected into the thecal sac and a fluoroscopic spot film was obtained. Then, the patient was placed into the upright position where neutral, flexion, and extension lateral x-rays were obtained.

The correct code in this example is 62304 (Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral).

As is now apparent, the difference between the two examples is the reference to the four-view spinal X-ray. This inability to discern between fluoroscopic imaging and radiologic imaging is one of the most problematic areas of myelography coding. In order to simplify this process as much as possible, follow these two steps when making a determination on which procedure code(s) to document:

1. If the physician only documents fluoroscopic guidance, code as an injection with fluoroscopic guidance (62284/77003).
          a. This includes references of "spot film" or "upright imaging."

2. If the dictation documents the above in addition to x-ray or CT imaging, code as a radiographic myelography (6230X).
          a. For CT scans, report both 6230X and the applicable CT procedure code.

Keep in mind: While most physicians generally perform the injection/fluoroscopy and radiographic imaging together, there are separate imaging and injection codes for a reason. If the physician is only involved one or the other, the combination code will not apply. Instead, you'll want to report the injection/fluoroscopy and radiographic imaging codes to their respective physicians.

The purpose of creating these two approaches of reporting myelography was to distinguish those performing an injection to prepare for subsequent CT imaging from those performing a traditional myelogram with different x-ray views," says Gregory Przybylski, MD, interim chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "With the CMS trend toward bundling procedures, when two or more spinal regions are evaluated with myelography, a single procedure CPT® 62305 is reported for the entire service," Przybylski details.