Radiology Coding Alert

Key: Understand the reason for fluoroscopy and check your payer preferences.

Coding for fluoroscopy with pain management injections can be problematic if you do not know what edits apply when reporting 64520 (Injection, anesthetic agent; lumbar or thoracic [paravertebral sympathetic]) with 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) or 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]). Learn more about how you can report these codes together. 

Start With the Procedure Intention

Your first step in knowing whether to report 77003 is to understand what’s being done and why. 

Foundation: The July 2008 CPT® Assistant shared a beginning point explanation: “Code 77002 is intended to be used to report fluoroscopic guidance during injection procedures when fluoroscopic guidance is required in the performance of needle placement in areas other than the spine, for pain management injection procedures…To differentiate, code 77002 rather than code 77003 should be reported to identify the fluoroscopic guidance performed in conjunction with injection codes 64400-64450, 64505-64530, 64600-64620, or 64630-64680, because this code more accurately describes the fluoroscopic guidance procedure performed for the anatomy involved. (i.e., these types of injections are not included in the list in the 77003 code descriptor)...”  

Interpretation: From a CPT® perspective, it would be appropriate to separately report 77002 for the fluoroscopic guidance of a lumbar sympathetic injection (64520). There are no CPT® parenthetical notes in the code book advising you to do otherwise. The December 2010 CPT® Assistant, however, directs providers to submit 77003 rather than 77002 when reporting fluoroscopic guidance in conjunction with 64520 – which could lead to confusion. Pay attention to the details regarding fluoroscopy in a particular case to gauge which code is better suited.

Pay Attention to Coding Edits

Medicare, however, takes a different stance regarding fluoroscopic guidance with 64520. In January 2010, Medicare’s Correct Coding Initiative (CCI) edits bundled both 77002 and 77003 into the vast majority of the somatic (644XX) and sympathetic (645XX) nerve injection codes.

Example: Both 77002 and 77003 are considered to be bundled as Column 2 codes into the comprehensive Column 1 code 64520 based on “Standards of medical/surgical practice.”  Chapter 1 of the NCCI manual states, “Many NCCI edits are based on the standards of medical/surgical practice. Services that are integral to another service are component parts of the more comprehensive service. When integral component services have their own HCPCS/CPT® codes, NCCI edits place the comprehensive service in column one and the component service in column two. Since a component service integral to a comprehensive service is not separately reportable, the column two code is not separately reportable with the column one code, thus preventing overbilling.”    

“CMS considers 77002 and 77003 bundled into 64520 according to the NCCI edits.  This means it would not be appropriate to report fluoroscopic guidance with 64520 for payers that follow the NCCI edits,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA. The edits mean that if you’re billing to Medicare or any commercial payer that also uses the NCCI edits to adjudicate claims, it would not be appropriate to separately bill for the fluoroscopic guidance (either 77002 or 77003). These NCCI edits do allow you to append a modifier (such as 59, Distinct procedural service) to 77002 or 77003 and report both procedures. Before taking that step, you need to ensure that the scenario and documentation meet the criteria to append modifier 59 (the fluoroscopic needle guidance was used with a different procedure that allows for separately billing 77002 or 77003). It is not appropriate to use a modifier to bypass the bundling edit if the fluoroscopic guidance was only used for the lumbar sympathetic injection.

Know the payer: Even with those coding restrictions in place, remember that not all payers follow the NCCI edits when considering claims. For those payers, you might still be allowed to report 77002 or 77003 with 64520.  

“This is one of the prime examples of the differences between the entity that creates the codes (AMA) and the payers who determine what they will or will not separately pay for,” says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver, Co. 

Bottom line: From a CPT® stance, you could separately report the 77002 or 77003 code for fluoroscopic guidance when performed with a lumbar sympathetic injection (64520). However, payers may have bundling edits that differ from the AMA stance and consider the needle guidance to be bundled into the injection. Staying current with your payers’ guidelines will help you know when you can successfully submit both codes. “Make sure you have any exceptions in payers guidelines in writing: however, obtaining them can be difficult,” says Michele Midkiff, CPC-I, PCS, RCC, an interventional and neuro-interventional radiology coding consultant in Mountain View, CA.