Orthopedic Coding Alert

In some cases, the orthopedist does not perform arthrography or issue a formal radiologic report with SI injections, but still uses fluoroscopy to identify the appropriate injection site. In these instances, you should not report 73542, but you can bill separately for the fluoroscopy with 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarach-noid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction). Consequently, an SI injection with fluoroscopy, but without a formal arthrography, would be billed as follows:

If your carrier denies fluoroscopy claims billed with 27096, appeal the denials with a copy of the CPT reporting guidelines (listed under the 27096 code descriptor in the CPT manual) along with a copy of your operative report to demonstrate medical necessity for the fluoroscopy and as proof that you did not perform an arthrogram with the injection.

Hip injections often require as much precision as SI injections. Therefore, orthopedists frequently use fluoroscopy to correctly identify the site. In fact, a comment in CPT following 20610* (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa) advises, "If imaging guidance is performed, see 76003, 76360, 76393, 76942." But coders report constant denials when billing 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) with 20610.

This occurs because CCI bundles 76003 into most injection procedures, including joint injections, says Trish Buskauskas, CPC, the chief executive officer of TB Consulting, a coding and reimbursement consulting company in Aliquippa, Pa. "CPT does refer coders to 76003 when reporting 20610, but CCI does not feel that there is enough medical necessity to support the use of guidance for a mere joint or muscle injection."

Buskauskas reminds coders that the AMA publishes CPT, whereas Medicare institutes the CCI edits, and the two do not always agree.

However, CCI may have instituted this edit because 20610 also applies to knee and shoulder injections, which are performed more often than hip injections but do not require fluoroscopic guidance, says Ryan Price, CPC, CCS-P, manager of coding operations at Aviacode, a coding outsourcing company in Salt Lake City. "The only joint injection normally performed under fluoroscopy is the hip injection," Price says, and therefore the CCI bundles fluoroscopy with 20610.

Price advises orthopedists whose patients require fluoroscopic guidance with hip injections to bill 76003 in addition to 20610, because you should bill for the services you perform. "I'm a strong believer in coding properly and fighting for what you should be paid, rather than coding to get the fastest reimbursement," Price states.

She advises orthopedists to append modifier -59 (Distinct procedural service) to 76003 billed with hip injections and to fight denials if they believe the fluoroscopy was medically necessary.

Remember to append modifier -26 (Professional component) to your fluoroscopic guidance claims unless your practice actually owns the fluoroscopy equipment.