Orthopedic Coding Alert

The answer depends on whose rules your payer follows

When you-re reporting a procedure that requires a -formal radiologic report,- do you have what it takes to support that criterion? Read on as in-the-trenches coders weigh in with their opinions on correctly reporting
these procedures.

Pay Attention to Arthrography and Epidurography 
 
Orthopedic practitioners see this situation most often with arthrography and epidurography procedures. -Our physicians will sometimes perform an epidurogram just before an epidural injection, or an arthrogram just before an SI [sacroiliac] joint injection,- says Eileen Lorenco, RHIT, CS, CPC, a coder with Lahey Clinic in Burlington, Mass.

Your challenge is to determine whether the provider's documentation of the service qualifies as a formal radiology report. If it does, you can report more detailed--and often higher-valued--codes for the procedures; if it doesn-t, you-re relegated to more general--and possibly lower-paying--codes.

The coding options for these arthrography and epidurography procedures include:
 
- 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation) for the SI joint arthrography.

- 72275 (Epidurography, radiological supervision and interpretation) for epidurography before an injection.

- 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) if documentation doesn't support using 73542 or 72275 for the procedure.

The code descriptors don't mention formal radiologic reports, so beginning coders might not realize that extra documentation is necessary. This important bit of information actually comes after the code definitions in the parenthetical notes.

Arthrography tip-off: A note following code 73542 states, -For procedure, use 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid). If formal arthrography is not performed, recorded, and a formal radiologic report is not issued, use 76005 for fluoroscopic guidance for sacroiliac joint injections.-

Epidurography direction: The third note following 72275 states, -Use 72275 only when an epidurogram is performed, images documented, and a formal radiologic report is issued.-
 
Translate It to Your Bottom Line 

Reporting 76005 for these procedures if you-ve actually performed a procedure that warrants 73542 or 72275 nudges your bottom line down.

Dollar difference: The Medicare Fee Schedule includes a nominal difference in professional charges for fluoroscopy ($32.10) versus arthrography ($32.20). But the jump to a professional charge of $40.82 for epidurography can be a good incentive for some providers to improve their documentation habits.

-The difference in amounts is not staggering but could add up over time,- Lorenco says. -The real bottom line comes into play when you consider whether the physician is giving the correct documentation to support billing an epidurogram or arthrogram.-

Example: If an auditor discovers that a physician doesn't have the documentation to support billing arthrography or epidurography, and that he repeatedly conducts the offense rather than making a one-time mistake, the physician could face steep financial penalties.

Determine What Constitutes a -Formal Report-

The American Academy of Orthopaedic Surgeons (AAOS) has commented on what constitutes a formal report in its Global Service Data books: -Interpretation of Radiographs: Interpretation of permanent images is separately reportable as long as a physician generates and signs the official interpretation of those images.-

The American College of Radiology (ACR) has established very specific guidelines for documenting diagnostic image findings. For example, they advise surgeons that -The report should include a description of the studies and/or procedures performed and any contrast media (including concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere.-
 To read the full text of the ACR's advice, visit www.acr.org/s_acr/bin.asp?CID=541&DID=12196&DOC=FILE.PDF.

In addition, -most payers like to see at least a separate note either in the operative report or following the op note,- says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

-In the past, our doctors would typically give us a one-liner within the body of an epidural operative report,- Lorenco says. -It would say something like, -Contrast was injected and the joint spaces were outlined in the typical Christmas-tree pattern.- Then they would try to bill an epidurogram. This was a concern to me because I didn't know if the note would be considered a formal radiological report in the event of an audit.-

Avoid Epidurogram Codes for Needle Placement

Research reasoning: After researching epidurograms and epidural injections, Lorenco found that physicians should use an epidurogram as a diagnostic tool. -An epidurogram should not be used merely for needle localization during an epidural procedure,- she says, -and I could not be sure from the one line in the report if my doctors were using it this way.-

New focus: When Lorenco began educating her physicians about the issue, she shifted her focus away from how a formal report should be set up. Instead of worrying about the length of the physicians- documentation, she instructed them on the most important factors: that their documentation supports the medical necessity for the epidurogram and that they document a description of any of the findings from the epidurogram.

-If they could do that in one line, fine,- Lorenco says. -Hopefully, we could justify to an auditor that this was a formal report basically because it contained all the information one would put in such a report. But if I couldn't clearly see medical necessity and findings within their documentation, then I would conclude that the epidurogram was only done for needle localization and therefore was not billable.- That meant reporting 76005 for the procedure instead of 72275.

Fluoro Code Doesn't Require Formal Report

If you don't have enough information to support 73542 or 72275, why do you use 76005 instead? Because you don't need a formal radiological report to submit the fluoroscopy code.

Explanation: CPT instructs you to report 76005 if you don't have a formal radiologic report. Other coding references explain that you use 76005 for guidance and needle confirmation for spinal procedures and that the physician only needs to dictate that he used fluoroscopy to confirm needle placement.