Orthopedic Coding Alert

Question: Our surgeon performed a disk biopsy at levels L5 and S1 using a Craig needle under fluoroscopic guidance. Which CPT codes should we report? 

Delaware Subscriber

Answer: Assuming that your surgeon biopsied the intravertebral disk (and not the vertebral body itself), you should report 21925 (Biopsy, soft tissue of back or flank; deep).
 
In addition, you should report 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) to represent the surgeon's work performing fluoroscopy.
 
If the physician performed the procedure in a facility, remember to append modifier 26 (Professional component) to 76003.