Radiology Coding Alert

Question: A patient had a fluoroscopic-guided lumbosacral myelogram. In the report, it documents the fluoroscopic guidance by stating “the spinal needle was advanced under fluoroscopic guidance into the thecal sac at the L5-S1 level.” Further down the report, the provider then states that “fluoroscopic and/or plain radiograph images were acquired of the lumbar spine.” Should I code this as 62304 or 62284/+77003?

Texas Subscriber

Answer: The problem here relates to the wording in the dictation report. Since the provider states “fluoroscopic and/or plain radiograph images were acquired,” you cannot make a positive determination of whether it’s one or the other — or both.

If the report only references a fluoroscopic-guided myelogram, you do not have enough documentation to support code 62304 (Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral). However, if you can confirm with the provider that he performed radiographic imaging, then 62304 is appropriate.

If the provider only confirms the fluoroscopic guidance, then you should use code 62284 (Injection procedure for myelography and/or computed tomography, lumbar) for the lumbosacral myelography and +77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure)) for the fluoroscopic guidance.

Remember: Radiographic imaging must consist of X-ray, computerized tomography (CT) scan, or magnetic resonance imaging (MRI) scan imaging. Terms such as fluoroscopic “spot film” are not sufficient to document radiographic imaging. This remains true even if the physician documents the number of fluoroscopic images obtained. Fluoroscopic imaging is an inherent part of the fluoroscopic procedure and does not meet the criteria to code as myelography with radiographic imaging.