Does Lidocaine Count for a ‘With Anesthesia’ Procedure?
Question: I have a medical record from an encounter at an outpatient radiology clinic. The radiologist injected the patient’s hip with lidocaine and contrast material under fluoroscopic guidance and then performed an MRI of the patient’s hip labrum. The radiologist imaged the hip labrum to evaluate for tearing. What codes should I use for the encounter? Arizona Subscriber Answer: You’ll need three CPT® codes to report this encounter based on the information you’ve provided. Use 27093 (Injection procedure for hip arthrography; without anesthesia) for the contrast media injection. Lidocaine is a local anesthetic, and with 27093 or 27095 (… with anesthesia), anesthesia refers to regional or general anesthesia. Assign add-on code +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)) to report the imaging guidance for the contrast injection. Lastly, you’ll use 73722 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)) to report the MRI with contrast of the patient’s hip labrum. Remember, to report a radiology procedure with contrast the contrast needs to be administered intravascularly, intra-articularly, or intrathecally. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
