Radiology Coding Alert

Mythbusters:

Unravel These 3 Image Guidance Coding Myths

Published on Wed Jan 25, 2023

Does location factor into the number of TPI guidance codes?

Knowing when to assign an image guidance code and when the service is part of a larger procedure can be confusing at times. Luckily, Radiology Coding Alert spoke with coding experts to bring clarity to your coding conundrums.

Read on to separate fact from fiction with three image guidance myths.

Myth 1: You Can Report a Fluoroscopic Guidance Code Alone

You can debunk this myth easily by reviewing the codes and their descriptors. The plus sign (+) in front of each code is a dead giveaway that this myth is false. “These guidance codes are add-on codes and would not be billed without a primary procedure,” says Kristen R. Taylor, CPC, CHC, CHIAP, associate partner of Pinnacle Enterprise Risk Consulting Services.

The three fluoroscopic guidance codes in the 2023 CPT^®code set include:

+77001 (Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure))
+77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure))
+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 Taylor notes above, the descriptor for each code includes a parenthetical instruction that means the add-on codes cannot be reported alone, and you must include the procedure for which the image guidance is required.

Scenario: A physician orders fluoroscopic guidance during an anesthesia injection into the ophthalmic branch of the patient’s trigeminal nerve.

For this scenario, you’ll report 64400 (Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)) prior to +77002 to correctly code the encounter. Code 64400 is the primary procedure for which +77002 was performed.

Myth 2: You Always Assign a Guidance Code for a ‘With Image Guidance’ Procedure

This myth is false — you don’t need to assign a separate image guidance code along with a primary procedure code that contains “with image guidance” in the code descriptor. If a procedure code’s descriptor includes the wording “with image guidance,” that means the image guidance is inherently included in the procedure, regardless of whether the provider uses the service.

Scenario: A physician performs arthrodesis with a bone graft on a patient’s lumbosacral region. During the procedure, a radiologist performs computed tomography (CT) guidance.

For this scenario, you need to assign only 22586 (Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace). Since 22586’s descriptor includes “with image guidance,” assigning 77012 (Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation) to report the CT guidance would result in a duplicate payment.

“You should not be reporting the guidance codes, but the documentation must clearly indicate guidance was used, and I would advise that the provider be in the habit of saying the type of guidance, as many procedures only allow for certain types of guidance,” says Ruby O’Brochta-Woodward, BSN, CPC, CPMA, CDEO, CPCO, CPB, COSC, CSFAC, coding supervisor at Coding Radiologists in Minneapolis, Minnesota.

For example, the following breast biopsy codes specify the image guidance modality in the code descriptor:

19081 (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 stereotactic guidance)
19083 (… first lesion, including ultrasound guidance)
19085 (… first lesion, including magnetic resonance guidance)

If a provider performed a percutaneous biopsy of one lesion on a patient’s breast, the provider should document the image guidance modality in the operative note, so you can assign the correct code to report the procedure. Query the provider to have them confirm the modality if the type of image guidance is missing from the operative note.

Myth 3: You Can Report Multiple Guidance Codes for Multiple Injections

Scenario: A provider performs two trigger-point injections (TPIs) in the patient’s left trapezius muscle. A radiologist performs ultrasonic guidance during the TPIs.

In this scenario, you’ll report 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) to report the TPIs and 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) to report the image guidance.

Why? Even though the radiologist performed imaging guidance for each of the two TPIs, you cannot report multiple instances of 76942 in this case. According to the 2023 National Correct Coding Initiative Policy Manual for Medicare Services, Chapter IX, Section G.3, CMS payment policy allows the provider to receive reimbursement for one unit of service during each patient encounter “regardless of the number of needle placements performed.” Since the injections occurred on the same anatomical structure, you’re unable to report multiple instances of the image guidance code (www.cms.gov/files/ document/medicare-ncci-policy-manual-2023-chapter-9.pdf).

At the same time, you cannot report a diagnostic ultrasound code and an ultrasound-guided procedure code together if the provider performed the procedures on the same body structure on the same date of service (DOS).

Scenario: A physician performs a limited diagnostic ultrasound of the patient’s right shoulder. After evaluating the results, the physician then performs an ultrasound-guided shoulder joint injection during the same encounter.

For this encounter, you can only report 20611 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting). “NCCI doesn’t allow for reporting of a guidance code with the same diagnostic modality if done on the same body part,” O’Brochta-Woodward says.

The National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits list 76882 (Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation) as a column 2 code for 20611 with a modifier indicator of “1.” This means 76882 is bundled into 20611, and the two codes cannot be reported separately unless 76882 is appended with an appropriate modifier, such as 59 (Distinct procedural service).

To report 20611 and 76882 separately, the injection and the diagnostic ultrasound need to be performed on different body structures.