Outpatient Facility Coding Alert

Question: What’s the difference between a radiographic arthrogram and a therapeutic injection if the provider performs both under fluoroscopic guidance?

South Carolina Subscriber

Answer: One of the more commonly miscoded procedures in the radiology specialty involves coders misinterpreting a therapeutic injection for an arthrogram study. Simply put, if the radiologist is injecting a steroid or anesthetic into the joint under fluoroscopic guidance, you’re not going to report the service as an arthrogram. Rather, the provider performs an arthrogram in order to visualize the joint using contrast. An arthrogram is an inherently diagnostic procedure.

Coder’s note: Just because you’re not coding an arthrogram doesn’t mean the provider will not be injecting contrast into the joint to confirm location of the needle tip. Contrast injection doesn’t automatically equate to an arthrography procedure.

Once you’ve got this established, you just need to pinpoint the areas in the dictation report that verify the physician’s services. For instance, for a therapeutic injection of the shoulder joint, you might see dictation resembling the following:

• Following intra-articular confirmation of needle tip location, 40 mg of Depo-Medrol^® and 5 cc of 0.5% Bupivacaine were injected into the glenohumeral joint under fluoroscopic guidance.

In this scenario, you should identify Depo-Medrol® as an anti-inflammatory glucocorticoid and bupivacaine as an anesthetic agent. Rather than coding this procedure as an arthrogram, you’ll code it as a joint injection under fluoroscopic guidance. You’ll report code 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) for the shoulder injection and +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)) for the fluoroscopic guidance. Further, you’ll want to make sure to bill for the Depo-Medrol with J1030 (Injection, methylprednisolone acetate, 40 mg).

Now, see how a traditional radiographic shoulder arthrogram dictation report differs from a therapeutic injection:

• The entrance site was localized using fluoroscopic guidance. Local anesthesia was achieved with 2% lidocaine solution. A 20-gauge needle was introduced with fluoroscopic guidance into the right shoulder joint capsule. Radiographic Isovue-300 was instilled in the right glenohumeral joint. There were no immediate post-procedure complications.

You’ll want to be sure not to misidentify the local anesthesia as a component of a therapeutic service. Rather, this is a routine injection to allow for the introduction of the 20-gauge needle for contrast injection. As you can see in the report, this is an exclusively diagnostic service. In the impression, you should expect to see the physician’s determination of what sort of pathology, if any, exists within the shoulder joint.

Tip: In addition to procedural documentation, be sure to review the original order(s) for the service.

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