Radiology Coding Alert

Question: Which code should we report for stereo-tactic-guided surgery or computer-assisted surgery that our radiologist performed during a sinus procedure?

North Dakota Subscriber

Answer: You should report 76355 (Computed tomography guidance for stereotactic localization). Prior to 2003, this code's descriptor included the word "axial" because most computed tomography (CT) guided direct image acquisitions occur in the axial plane. Radiologists can perform CT direct acquisition imaging in other planes, however, so CPT removed "axial" from the descriptor this year. Therefore, you should report this code for the CT guidance that you performed in the coronal plane for your sinus study.