Radiology Coding Alert

According to CMS, interventional and diagnostic radiologists reported the fluoro-scopic guidance code 76005 more than 50,000 times in 2001. Despite the code's popularity, however, many practices have difficulty collecting payment for their fluoro-scopic guidance services when performed with epidural injections. The following five steps can help your practice collect appropriate fluoroscopy reimbursement.

Several subscribers report that their carriers deny fluoroscopic guidance (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) and bundle it into the following epidural injection codes:

62310 - Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

62311 - ... lumbar, sacral (caudal).

The National Correct Coding Initiative ( CCI Edits ) does not include any edits barring practices from reporting the fluoroscopic guidance and epidural injection codes together, so you should inspect your claim to ensure that you submitted it correctly. And if you did, you should appeal the denial.

Step 1: Confirm Your Guidance Code. Although 76005 is the appropriate fluoroscopic guidance code to submit with epidural injection claims, some coders still report 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) instead.

"CPT Codes 2000 introduced 76005 as the new code for fluoroscopy with spinal injections, leaving 76000 for use in conjunction with other services," says Julie Jarvis, owner of Underwood Billing, a coding and billing consulting firm in Orlando, Fla. "Unfortunately, some practices are following old advice and are still reporting 76000 with 62310 and 62311."

Radiology coders who are new to epidural injection billing might refer to outdated LMRPs or back issues of CPT Assistant to support billing 76000 with their epidural claims. The December 1998 CPT Assistant, for example, advised practices to report 76000 with epidural injections. More recent issues of the publication have updated this advice to reflect the more accurate code 76005, but some coders don't realize that and are still following the obsolete advice.

Step 2: Confirm Your Carrier's Guidelines. Even if you submit your claim with the appropriate fluoroscopic guidance code (76005), your carrier may think you've used the incorrect fluoroscopy code. "Believe it or not, there are still insurers out there that haven't updated their systems since 2000," Jarvis says. Also, "it's not that unusual for workers' compensation or other private insurers to still require 76000 instead of 76005. Remember that private payers can and do make their own rules when it comes to the codes they prefer you to report."

Confirm that your Medicare or private insurance carrier has updated its system to reflect 76005's addition and that your private payers require 76005 instead of a different fluoroscopy code with your epidural claims.

Step 3: Check for Documentation of Formal Contrast Study. When billed with epidural injections, Medicare payers will reimburse you either for fluoro-scopic guidance or for the radiological supervision and interpretation of a formal contrast study, but not both. The local medical review policy (LMRP) for Palmetto GBA, South Carolina's Part B carrier, states, "Fluoroscopic guidance and localization is reported by CPT code 76005, unless a formal contrast study is performed, in which case the use of fluoroscopic guidance is included in the supervision and interpretation codes."

To report a formal contrast study, such as an epidurogram or myelogram, the physician must provide a formal radiological report of the contrast study. When fluoroscopic guidance is provided in conjunction with a spinal or paraspinal injection procedure, the physician should also render a report of that guidance service. The following codes apply to contrast studies that radiologists perform by way of spinal injection of contrast:

72240 - Myelography, cervical, radiological supervision and interpretation

72255 - Myelography, thoracic, radiological supervision and interpretation

72265 - Myelography, lumbosacral, radiological supervision and interpretation

72270 - Myelography, entire spinal canal, radiological supervision and interpretation

72275 - Epidurography, radiological supervision and interpretation

See the "Fluoroscopy Clip-and-Save Chart"  for more information on when you can report formal contrast studies and when you should bill for fluoroscopic guidance instead.

Step 4: Determine Whether Modifier -26 Is Required. The Physician Fee Schedule includes relative value units for the professional and technical components of 76005. Therefore, if the physician does not own the fluoroscopy equipment, you should append modifier -26 (Professional component) to the fluoroscopy code, says Kathy Pride, CPC, CCS-P, an HIM applications specialist and coding and reimbursement expert with Quadramed, a California-based consulting firm. Medicare will reimburse the facility or hospital for the claim's technical portion, and will pay you for the professional component.

Step 5: Appeal. If your claims pass muster on our first four steps and Medicare or other payers still deny your claim, you should appeal. Send your carrier a copy of the NCCI edits, which demonstrate that 76005 is not a component of 62310 and 62311. In addition, if your LMRP provides specific direction on epidural injections with fluoroscopic guidance, you should send a copy of the policy and highlight the portion that directs you to report 76005 with epidural injections.

The radiologist should write a short appeal letter, and you should send the claim as a "hard-copy claim" instead of electronically.