Radiology Coding Alert

Laterality modifiers can help your claim.

Providers may use imaging guidance while performing a biopsy, needle aspiration, or an injection to ensure the procedure is proceeding correctly. And that means you have to understand a wide variety of possibilities for coding this radiology essential.

Plus, modality can affect your code choice because imaging guidance describes a radiologist’s use of various imaging tools, such as fluoroscopy (real-time X-rays viewed on a monitor), ultrasound (US), magnetic resonance imaging (MRI), or computed tomography (CT), to view the body’s structures during noninvasive or percutaneous procedures.

Check out these tips for coding imaging-guidance procedures.

Tip 1: Understand Joint Sizes for Arthrocentesis Code Selection

During arthrocentesis (joint aspiration), a provider directs a needle through the patient’s skin and inserts the needle into a joint or bursa (fluid-filled sac in the joint) to administer a drug or remove fluid. The procedure’s intention is purely therapeutic. Sometimes, the provider will use US to precisely guide the needle into the joint or bursa.

If you have documentation that indicates the provider performed arthrocentesis with US guidance, you can choose from three codes to assign:

• 20604 (Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting)
• 20606 (Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting)
• 20611 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting)

The main difference between the three CPT^® codes is the size of the joint the provider injects. You’ll assign 20604 if the documentation states arthrocentesis was performed on the patient’s fingers or toes. If the procedure is performed on a slightly larger joint, such as the wrist, elbow, or ankle, you’ll select 20606. However, if the provider injects a drug into the patient’s shoulder, knee, or hip, you’ll assign 20611.

Parenthetical note: Parenthetical notes under 20604, 20606, and 20611 instruct you to not report these codes with 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation). CPT^® codes 20604, 20606, and 20611 are combination codes that include US guidance, so assigning 76942 separately is unnecessary.

Tip 2: Report RS&I Codes When Necessary

Several CPT^® codes include imaging guidance, so you shouldn’t report the imaging guidance separately if the guidance is included in the base service. However, if a procedure from the Medicine section of the CPT^® code set or a surgical procedure doesn’t include imaging, and imaging guidance is necessary for the provider to complete the procedure, then you may report a radiological supervision and interpretation (RS&I) code.

To report RS&I codes, such as 77012 (Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation), the provider must fulfill two requirements according to the Radiology section guidelines in the 2022 CPT^® code set:

1. Include image documentation in the patient record; and
2. Provide a procedure report or separate imaging report that includes written documentation of interpretive findings of information contained in the images and radiologic supervision of the service.

“When you get into the RS&I guidelines, it says ‘All RS&I codes require image documentation in the patient’s permanent record,’ so it’s important to make sure those images are there,” says Nate Felt, MS, ATC, PTA, CPC, senior consultant for orthopedic physician coding at Intermountain Healthcare during AAPC’s March 17, 2021, webinar, “Diving into Diagnostic Radiology Coding and Documentation.” Simultaneously, the guidelines also state that written documentation of the findings and supervision of the service should be included in the report.

Can US guidance be reported? If a radiologist performed a US procedure, such as 76975 (Gastrointestinal endoscopic ultrasound, supervision and interpretation), you cannot report 76942 separately. According to Chapter 9, Section H.12, of the 2022 National Correct Coding Initiative Policy Manual for Medicare Services, “Radiological supervision and interpretation codes include all radiological services necessary to complete the service. CPT^® codes for … ultrasound/ultrasound guidance (e.g., 76942, 76998) shall not be reported separately” (www.cms.gov/files/document/chapter9cptcodes70000-79999final11.pdf).

Tip 3: Append Your Assigned Code With Laterality Modifiers

Scenario: A patient presents to a clinic to have a biopsy of an abnormal mass in their right breast. The radiologist discovered the mass during the patient’s mammography the week before. Using MRI guidance, the physician performs a core needle biopsy and removes tissue from the lesion for testing.

In this scenario, you’ll assign 19085 (Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance). CPT^® code 19085 is a combination code that includes the biopsy of the breast and MRI guidance. The descriptor also calls out “with placement of breast localization device(s), … when performed,” but the provider doesn’t need to perform this portion of the service for you to assign the code.

Check your individual payer’s preferences to confirm if any modifiers need to be appended to the codes. For instance, some payers may want you to specify laterality in the above scenario, so you may append RT (Right side) to 19100 to ensure proper reimbursement.

As another example, you may append digit-specific modifiers, such as FA (Left hand, thumb) or T2 (Left foot, third digit), to arthrocentesis codes to show which fingers or toes were injected.