Podiatry Coding & Billing Alert

Question: The patient came in complaining of persistent pain in the right ankle. After a thorough examination, the provider decided to perform an arthrography on the right ankle. The provider began the procedure by cleaning and numbing the area around the ankle. A small needle was then carefully inserted into the joint space. To ensure the needle was accurately placed, the provider used fluoroscopic guidance. Once the needle was correctly positioned, the contrast material was injected into the joint. Encounter notes indicate that the provider performed a right ankle arthrography, with radiological supervision and interpretation noted. The provider also used fluoroscopic guidance for needle placement. The X-ray occurred at the local hospital using their X-ray equipment. How should I code this encounter?

Georgia Subscriber

Answer: On your claim, you will report:

• 73615 (Radiologic examination, ankle, arthrography, radiological supervision and interpretation) for the radiological supervision and interpretation, as well as injecting contrast into the ankle joint and the radiological supervision and interpretation
• 27648 (Injection procedure for ankle arthrography) for the fluoroscopy to guide the needle placement
• Modifier RT (Right side) appended to 73615 to indicate laterality for the X-ray

Remember: The coding for the use of the hospital’s X-ray equipment would typically be handled by the hospital’s billing department, not the provider’s office. The provider’s office would only bill for the professional component (the actual performance and interpretation of the procedure).