Radiology Coding Alert

Payment and coding confusion increased two years ago when CPT Codes implemented new codes for diskography, myelography and epidurography. Since then, radiologists and coders have struggled to learn the new system and correctly pair codes that appropriately describe the work performed.

You must understand the distinctions among these three categories of imaging study, each of which may be used to pinpoint the cause of back pain, says April Brazinsky, CCS, coding specialist for the Community Hospital of the Monterey Peninsula in California. Additionally, radiologists order diagnostic spinal injections to identify the precise anatomic location for administration of a spinal block as a secondary treatment during cancer therapy. Contrast is injected at various anatomic locations related to the spinal column, and radiographic images are obtained. These studies allow the radiologist to identify the source of the signs and symptoms, or to eliminate a specific cause and seek answers elsewhere.

Defined as contrast imaging of the intervertebral disks, diskography ascertains the integrity of the intervertebral disk by using both the pressure of injected intradiskal contrast to reproduce the patient's symptoms and the appearance of the injected radiographic contrast material. This process allows the radiologist to see any cracks or fissures in the patient's vertebrae, notes Lisa Grimes, RT [R]), radiology special procedures technologist and reimbursement specialist for the University of Texas/Houston Health Science Center. ICD-9 Codes most often reported for diskography include disk herniation (e.g., 722.0, Displacement of cervical intervertebral disc without myelopathy), myelopathy (721.1, Cervical spondylosis with myelopathy) and radiculopathy (729.2, Neuralgia, neuritis, and radiculitis, unspecified).

Diskography involves two components, she says, both of which can be coded: 1) an injection or surgical service and 2) radiological supervision and interpretation (RS&I) service. Coders would choose either 62290* (Injection procedure for diskography, each level; lumbar) or 62291* (... cervical or thoracic) depending on the injection's location. In addition, codes 72295 (Diskography, lumbar, radiological supervision and interpretation) for the lumbar region or 72285 (Diskography, cervical or thoracic, radiological supervision and interpretation) for the cervical or thoracic region would be paired with the corresponding injection code.

In many cases, the physician performs several injections at various levels along the spine. The AMA allows both the injection and the RS&I codes to be reported multiple times. The code descriptions make this clear, outlining that the code is assigned for "each level." This indicates that the number of units should be indicated next to the code when the claim is submitted and that no additional modifier is necessary. For instance, if three injections were performed at three different levels of the lumbar spine, the coder would enter 62290 x 3.

Nonetheless, coding experts report that claims are often denied unless modifier -51 (Multiple procedures) is appended to the second and subsequent instances of the code. If this occurs, coders should list each service on a separate line. The first entry would carry no modifier, while subsequent entries would be assigned modifier -51.

Myelography is also a study related to the spine and its contents but is defined as contrast imaging of the spinal cord and nerve roots by injection of intrathecal contrast. It may be used for the same conditions as diskography, as well as metastatic cancer, paraplegia, paraparesis, and loss of bladder or bowel control, for instance. "This procedure produces an image of the contents of the spinal canal," Grimes says. "It would be performed, for instance, to show if there is an impingement and pressure within the spinal canal or a blockage." These could be secondary to disk or bony abnormalities, or tumors of the cord and/or its covering layers.

Two procedure codes are available to report the myelography procedure's injection portion, again depending on the injection's location. CPT 62284* (Injection procedure for myelography and/or computerized axial tomography, spinal [other than C1-C2 and posterior fossa]) describes the delivery of contrast in the lumbar or thoracic region (most typically in the lumbar region), while 61055* (Cisternal or lateral cervical [C1-C2] puncture; with injection of medication or other substance for diagnosis or treatment) is reported for cervical injections. In either case, spinal fluid may be collected and subsequently sent to the pathology laboratory for analysis. The collection of such specimens is not separately reportable.

Unlike diskography, CPT provides four codes to describe the RS&I portion of the procedure, she adds: