Bundling of radiology codes into surgical codes continues

2014 08 29 09 35 55 499 Majchrzak Jeff 200

Not surprisingly, many of the 2015 changes to CPT codes made by the American Medical Association (AMA) include the bundling of codes for imaging guidance -- as well as radiological supervision and interpretation (S&I) -- into surgical codes.

In addition to being aware of these and other code changes, radiologists and their staff must also go the extra mile to review the introductory notes at the start of certain sections of code documentation, along with the parenthetical notes added under the new and revised surgical codes.

Jeff Majchrzak of Panacea Healthcare Solutions.Jeff Majchrzak of Panacea Healthcare Solutions.

To be in compliance, providers will need to change the way they code certain surgical procedures, including those listed below. Revisions are shown with strikethroughs to indicate words that have been deleted and underlining to mark words that have been added.

Joint injection and aspiration

Three new joint injection and aspiration codes join the existing three codes, which have been revised.

If a joint injection and aspiration is performed under ultrasound guidance, you will choose one of the three new codes, which bundle the ultrasound with the primary procedure into one code. As with all ultrasound-guided procedures, permanent recording is required:

  • 20604: Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting
  • 20606: Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., 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 (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting

AMA revised the three existing codes for 2015 with the code descriptions changed to include "without ultrasound guidance." These codes would be assigned if a joint injection/aspiration is performed without any imaging guidance, or with fluoroscopic, CT, or MR guidance. If fluoroscopic, CT, or MR guidance is used, assign the modality-specific S&I code in addition to one of the following surgical codes:

  • 20600: Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance
  • 20605: Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
  • 20610: Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance

One of the imaging codes below also would be assigned with one of the above three codes, as appropriate:

  • 77002: Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
  • 77012: CT guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological S&I
  • 77021: MR guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device), radiological S&I

Percutaneous vertebroplasty and vertebral augmentation

Be sure to look for this new section, which includes new codes 22510-22515. These codes describe procedures for percutaneous vertebral augmentation that include vertebroplasty of the cervical, thoracic, lumbar, and sacral spine and vertebral augmentation of the thoracic and lumbar spine.

The new section includes the following definitions:

  • Vertebroplasty: the process of injecting a material (cement) into the vertebral body to reinforce the structure of the body using image guidance
  • Vertebral augmentation (kyphoplasty): the process of cavity creation followed by the injection of the material (cement) under image guidance

The procedure codes listed below include bone biopsy when performed, moderate sedation, and the necessary imaging guidance. As always, assign one primary procedure code per encounter and an add-on code for additional levels treated at the same session, whether in the same spinal region or another.

Vertebroplasty

  • 22510: Percutaneous vertebroplasty (bone biopsy included when performed), one vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic
  • 22511: Lumbosacral
  • 22512: Each additional cervicothoracic or lumbosacral vertebral body (list separately in addition to code for primary procedure)

Vertebral augmentation (kyphoplasty)

  • 22513: Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), one vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic
  • 22514: Lumbar
  • 22515: Each additional thoracic or lumbar vertebral body (list separately in addition to code for primary procedure)

Sacral augmentation (sacroplasty)

The two category III codes below refer to the creation of a cavity within a sacral vertebral body followed by injection of a material to fill that cavity. Although the sacroplasty codes did not change, their descriptions changed. As shown below, the descriptions now include bone biopsy and imaging guidance. When treating the sacrum, sacral procedures are reported only once per encounter:

  • 0200T: Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, one or more needles, includes imaging guidance and bone biopsy, when performed
  • 0201T: Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, two or more needles, includes imaging guidance and bone biopsy, when performed

Myelography

As with the joint injection and aspiration codes, AMA did not delete the existing radiological S&I codes for this procedure, but it did add a new set of combined codes for certain situations. It also added several parenthetical notes below each of the existing S&I codes:

  • 72240: Myelography, cervical, radiological S&I
  • 72255: Myelography, thoracic, radiological S&I
  • 72265: Myelography, lumbosacral, radiological S&I
  • 72270: Myelography, two or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological S&I

If one physician injects and another physician images and interprets, each would assign the code appropriate to the component performed. The physician who supervises and interprets the imaging would assign one of the S&I codes above, while the physician who injects the intrathecal contrast would assign 61055 (C1-C2) or 62284 (lumbar):

  • 61055: Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment (C1-C2)
  • 62284: Injection procedure for myelography and/or CT, spinal lumbar (other than C1-C2 and posterior fossa)

One of the S&I codes above and injection code 61055 would also be assigned when one doctor performs a myelogram with cervical injection of contrast.

When the same physician performs both a lumbar injection of contrast and the imaging, choose a code from the 62302-62305 series instead of assigning injection code 62284 and an S&I code (72240-72270):

  • 62302: Myelography via lumbar injection, including radiological S&I; cervical
  • 62303: Thoracic
  • 62304: Lumbosacral
  • 62305: Two or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical)

Myelogram codes are only assigned when a formal radiographic myelogram is ordered, performed, and documented. Confirmation of intrathecal needle position prior to CT spine is not considered a myelogram and only the injection and CT codes should be assigned.

Dual-energy x-ray absorptiometry (DEXA) scan with vertebral fracture assessment (VFA)

For 2015, AMA deleted 77082 -- vertebral fracture assessment by dual-energy x-ray absorptiometry. A new parenthetical note directs the coder to assign 77086 (description below).

When a VFA is performed at the same session as an axial skeleton DEXA, assign the following code:

  • 77085: DEXA, bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine), including VFA

When a VFA is performed using DEXA, but a formal DEXA scan is not performed, assign the following:

  • 77086: VFA via DEXA

Changes similar to the above can be expected over the next few years as AMA and imaging specialty societies continue to review and revise radiology codes to better capture current practice.

According to the summaries of CPT Editorial Panel meetings, potential changes for 2016 include new codes for plain films of the thoracolumbar spine, as well as combined hip and pelvis exams, and genitourinary catheterization.

Jeff Majchrzak is vice president of clinical consulting services, radiology, for Panacea Healthcare Solutions. In his role as consultant, he conducts CPT coding assessments for both hospitals and physicians, evaluates administrative policies and procedures, and helps develop quality assurance programs to ensure complete and compliant coding and billing. Jeff trains both radiology and cardiology staff (on both technical and professional billing issues) in correct coding practices. Jeff contributes to numerous publications by MedLearn Publishing (a division of Panacea) and is a sought-after national speaker on coding and reimbursement for radiology, interventional radiology, nuclear medicine, and cardiology. Jeff can be reached at [email protected], or visit Panacea Healthcare Solutions at www.panaceahealthsolutions.com.

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