Outpatient Facility Coding Alert

Distinguish between radiographic and fluoroscopic imaging in the report.

If your outpatient facility or ambulatory surgery center (ASC) is familiar with arthrogram services, you know there’s a lot to take into account if you want to get the coding processes right on the first try.

That’s because you’ve got to consider the injection service, the fluoroscopic guidance, and the imaging that may follow. You’ve also got to understand how a radiographic arthrogram differs from a computed tomography (CT) or magnetic resonance imaging (MRI) arthrogram. As you’ll see, it’s not always as simple as spotting the arthrography service that includes an enhanced CT or MRI scan.

Have a look at some crucial arthrogram guidelines and tips on coding processes — and drive the point home with a helpful shoulder arthrogram example.  

Define 2 Different Types of Arthrogram

Coders for both interventional and diagnostic radiologists should be able to identify the difference between a traditional radiographic arthrogram and a computed tomography (CT) or magnetic resonance (MR) arthrogram. Before diving into any coding considerations, however, you’ll want to get a little context as to when a physician may perform one or the other.

“Generally speaking, the only reason you will perform radiographic imaging following an arthrogram is if you were performing a standard arthrogram without an MRI,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “You may come across this scenario when the patient is unable to receive an MRI due to pacemaker status, for instance. In this case, the provider may either opt for a CT scan following the arthrogram or exclusively rely on radiographic imaging,” explains Rosenberg.

With this information in mind, you should know that you will not typically come across a CT or MRI arthrography that includes radiographic imaging. Rather, the patient will usually have a fluoroscopic-guided arthrogram without radiographic imaging followed by the CT or MRI enhanced by intraarticular contrast injection.

Check Out This Shoulder Arthrogram Example

Now that you know what sort of clinical arthrography scenarios to expect, you’ll want to make sure you’ve got all the coding fundamentals down pat. Using a shoulder arthrography as an example, you’ll want to report the following for a radiographic arthrography of the shoulder:

• 23350 (Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography)
• 73040 (Radiologic examination, shoulder, arthrography, radiological supervision and interpretation).

First, you’ll want to make a note that 73040 is inclusive of both fluoroscopic and radiographic imaging. Specifically, you’ve got to analyze the dictation report to confirm that true radiographic imaging was performed in addition to fluoroscopic guidance. This means discerning between X-ray imaging and fluoroscopic spot films. If the report for the injection states something along the lines of “following exercise, 4 spot films of the left shoulder joint were obtained,” then you should not consider this a radiographic arthrogram and proceed to report the following codes:

• 23350
• +77002.

Be Considerate of More Than Just the Report

That’s not the only pitfall you need to be on the lookout for, though. For instance, the exam header may be erroneously worded as an “X-ray Shoulder Arthrogram.” This sort of exam header is most likely applied to any and all injection/fluoroscopy services for the arthrogram of the respective area. Unless X-ray imaging is specifically documented in the report, you should not consider these reports to be radiographic arthrograms, and should therefore not report 73040. 

In the scenario above that doesn’t include X-ray imaging following the injection, you’ll more often than not see an accompanying CT or MRI scan labeled as a CT Arthrogram or MR(I) Arthrogram, respectively. When a CT or MRI follows an arthrography service, you should yield to CPT^® instructions noted under code 23350. For instance, CPT^® guidelines provide the following instructions for CT Arthrogram coding:

• “(When fluoroscopic guided injection is performed for enhanced CT arthrography, use 23350, +77002, and 73201 or 73202).”

You might be wondering why these scans are described as “enhanced” services. In fact, there’s a good reason for the labeling. “A traditional MRI and/or CT scan is viewing body structure, but there are times when minuscule anatomy is not seen well,” says Sabrina Goddard, CPC, billing manager at Open Imaging in Salt Lake City, Utah. “The terminology ‘enhanced’ is confirming another component was brought in to allow for a better, more focused visualization of said structure-contrast materials.

“Furthermore, intravenous [IV] contrast will make blood vessels and arteries more visible on an image and can confirm for more accurate location of blood path. Whereas an injection into the joint itself is localized and contained, intraarticular injection of contrast will bring the more subtle ‘articular structures’ — ligaments and cartilage — to light for a more focused visualization, especially given that these types of structures do not have a direct blood supply. Both types of contrast have a place dependent on the anatomy being imaged, and both warrant the term ’enhanced,’” explains Goddard.

With that in mind, the coding processes won’t change when reporting the appropriate enhanced scan. Despite the fact that contrast has been performed during the injection stage, you’ll still report the CT or MRI using a “with contrast” code, such as 73222 (Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)) for an MR Arthrogram. In rare cases, the patient may receive an MRI or CT scan without contrast prior to the injection followed by another MRI or CT scan after the injection. In these instances, you’ll report the appropriate “with and without contrast” code.

---