Radiology Coding Alert

Keys to deciphering myelography dictation reports

Any experienced interventional radiology coder knows that there’s a science to correctly coding myelographies. But in order to reach the correct set of codes every time, it’s important to have a firm grasp on how these procedures actually work. Here’s a quick refresher:

Myelography is an imaging study performed to identify abnormalities within the subarachnoid space of the spine. This area between the spinal cord and the vertebrae is visualized using a contrast dye injection via fluoroscopic guidance. Physicians may also perform radiographic imagining such as X-rays and Computed Tomography (CT) scans alongside this procedure.

Find Site of Injection

Myelography injections will most typically occur via the lumbar spine; with the alternative approach being a C1-C2 or posterior fossa injection. For cervical, thoracic, or lumbar myelographies via the C1-C2 or posterior fossa approach, you’ll apply one (or more) of the following:

• 61055, Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment (Injection only)
• 72240, Myelography, cervical, radiological supervision and interpretation (Imaging only)
• 72255, Myelography, thoracic, radiological supervision and interpretation (Imaging only)
• 72265, Myelography, lumbosacral, radiological supervision and interpretation (Imaging only)
• 72270, Myelography, 2 or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation (Imaging only).

If the injection follows the more traditional lumbar approach, you’ll select from one of the following:

• 62284, Injection procedure for myelography and/or computed tomography, lumbar
• 72240/72255/72265 (Imaging only)
• 62302, Myelography via lumbar injection, including radiological supervision and interpretation; cervical 
• 62303, Myelography via lumbar injection, including radiological supervision and interpretation; thoracic 
• 62304, Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral 
• 62305, Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical).

Take note: If a physician performs a myelography via the C1-C2 or posterior fossa route, there is no combination code that includes both imaging and radiological supervision and interpretation. In cases where the physician performs both, you’ll want to apply both the imaging and radiological supervision and interpretation codes (61055, 72240/72255/77265/72270). You will NOT include a fluoroscopic guidance code in addition to these two.

Determine What Services Provider Performed

Correct myelography coding requires a coder to be able to see whether the dictation supports an injection, radiological supervision and interpretation, or both.

One of the most common misconceptions when coding myelographies is making the incorrect assumption that a fluoroscopic-guided myelography includes both imaging and injection codes (6230X). A fluoroscopic-guided myelography (via the lumbar spine) would actually be coded as 62284/77003 rather than 6230X. The distinguishing factors between these two codes, however, can come down to one or two important keywords.

Decide Between Fluoroscopic-Guided, Radiographic Myelography

The dictation reports documenting these two procedures might look nearly identical at first sight. The key (and perhaps only) difference will be the description of radiographic imaging on the radiographic myelography.

One of the most common pitfalls interventional radiology coders face is making the assumption that a “spot film” is equivalent to radiographic imaging. On the contrary, “a fluoroscopy includes a spot film as an inherent part of the procedure,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “If true radiographic imaging is performed during the myelography — and the the physician also performs the injection — you’ll want to disregard the fluoroscopy code entirely as it’s bundled into the combination code 6230X.” Let’s take a look at a couple of exams to help underline the scenarios in which you’d apply each set of codes.

Example:

After informed oral and written consent was obtained and a timeout was performed, fluoroscopy was used to evaluate the lumbar spine. The right L4-L5 interlaminar space was identified. The overlying skin was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the skin and subcutaneous tissues. Then, a 22-gauge spinal needle was advanced under intermittent fluoroscopic guidance into the thecal sac. Clear CSF was noted in the needle hub. Then, 8 ml of omnipaque-240 IV contrast was injected into the thecal sac and a fluoroscopic spot film was obtained. Upright imaging reveals narrowing of the L2-L3 column. No instability is identified.

The correct codes in this scenario are 62284 and 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid] [List separately in addition to code for primary procedure]).

As mentioned before, fluoroscopic guidance with a spot film is not equivalent to radiographic imaging. Since this dictation does not warrant the inclusion of imaging, the all-encompassing code 62304 (Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral) is not applicable here. Instead, you’ll opt to include 62284 to document the injection and 77003 to document the use of fluoroscopic imaging. Next, let’s look at an example where radiographic imaging is included with the myelography.

Example:

After informed oral and written consent was obtained and a timeout was performed, fluoroscopy was used to evaluate the lumbar spine. The right L4-L5 interlaminar space was identified. The overlying skin was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the skin and subcutaneous tissues. Then, a 22-gauge spinal needle was advanced under intermittent fluoroscopic guidance into the thecal sac. Clear CSF was noted in the needle hub. 8 ml of omnipaque-240 IV contrast was injected into the thecal sac and a fluoroscopic spot film was obtained. Then, the patient was placed into the upright position where neutral, flexion, and extension lateral X-rays were obtained.

The correct code in this example is 62304.

As is now apparent, the difference between the two examples is the reference to the four-view spinal X-ray. This inability to discern between fluoroscopic imaging and radiologic imaging is one of the most problematic areas of myelography coding. In order to simplify this process as much as possible, follow these two steps when making a determination on which procedure code(s) to document:

1. If the physician only documents fluoroscopic guidance, code as an injection with fluoroscopic guidance (62284/77003)
            a. This includes references of “spot film” or “upright imaging.”

2. If the dictation documents the above in addition to X-ray or CT imaging, code as a radiographic myelography (6230X).
            a. For CT scans, report both 6230X and the applicable CT procedure code

Keep in mind: While most physicians generally perform the injection/fluoroscopy and radiographic imaging together, there are separate imaging and injection codes for a reason. If the physician is only involved in one or the other, the combination code will not apply. Instead, you’ll want to report the injection/fluoroscopy and radiographic imaging codes to their respective physicians.