ACR Radiology Coding Source™ March-April 2006
This article will discuss many of the most widely performed spinal diagnostic and therapeutic procedures. This should provide a concisely stated reference document for radiology coders, covering procedural descriptions, CPT coding, and a comprehensive list of specific coding rules for the procedures included in the article. All coders should be reminded to consult their Medicare carrier local coverage determinations (LCDs) for limitations on coverage due to medical necessity, and to consult other individual payers for their specific coding reporting requirements.
A lumbar puncture may be performed for diagnostic or therapeutic purposes. Diagnostic lumbar puncture is a procedure which is done to remove a small amount of cerebrospinal fluid for laboratory testing, and is reported with CPT code 62270. A therapeutic lumbar puncture is reported with CPT code 62272. Fluoroscopy may or may not be required to assist with visualization of specific spinal anatomy for lumbar puncture needle placement. If fluoroscopy is utilized for lumbar puncture, fluoroscopic guidance should be additionally reported with CPT code 76005.1
Myelography is a diagnostic study utilizing contrast in order to visualize the spinal subarachnoid space and its contents. This study may be performed with attention to any or all areas of the spine. The contrast injection portion of the procedure is typically done through the lumbar area, and reported with CPT code 62284 (Injection procedure for myelography and/or CT, spinal). Injection of contrast for myelography may also be performed through the cervical region, which is reported with CPT code 61055 (Cisternal or lateral cervical (C1-C2) puncture, with injection of medication for diagnosis or treatment). The surgical code is reported only once per encounter, even if more than one spinal area is studied.2 For example, if the cervical, thoracic, and lumbar areas were all studied from one lumbar puncture, report 62284 only once. However, in the unusual case of a myelogram of the entire spine requiring both a lumbar and cervical puncture, report both 62284 and 61055.3 Surgical injection codes for myelography include the withdrawal of a small amount of cerebrospinal fluid, and a diagnostic or therapeutic lumbar puncture code should not be reported in addition to the injection for myelography. The radiological supervision and interpretation (RS&I) or imaging codes for myelography are 72240 for cervical, 72250 for thoracic, or 72265 for lumbosacral, when only one spinal area is studied during the procedure. The RS&I code 72270 (Myelography, two or more regions) should be reported when more than one spinal area is studied during the procedure. Fluoroscopic guidance is included in the 72240-72270 codes; therefore, 76005 is not reported separately. Note that when a postmyelography CT is performed, it is coded as a "with contrast" CT study.
Discography, a diagnostic study performed by injection of contrast into an intervertebral disc, is reported with CPT codes 62290 and 72295 when performed in the lumbar region. Cervical or thoracic discography may be reported with 62291 and 72285. Both the surgical and RS&I codes should be reported once for each level injected and studied.
Epidurography consists of a diagnostic evaluation following an injection of contrast into the epidural space, and must include permanent image-recording and a formal diagnostic radiology report. The injection of contrast alone is not sufficient to code for a formal diagnostic study, since CPT defines spinal injection surgical codes as being inclusive of the injection of contrast. In epidurography, the epidural space is visualized to evaluate the nerves and nerve roots, and to identify whether there is free flow of contrast within the epidural space. Areas of scarring, swelling, narrowing, or abnormalities of the nerves can be seen. Based on the findings of epidurography, treatment options can be considered. When epidurography is performed as a separate diagnostic study, CPT code 72275 may be used. The injection procedure for epidurography is coded separately with 62311. Code 72275 includes the use of fluoroscopy. If epidural injections are performed in separate regions of the spine, each region may be coded and reported separately.4 For example, to report epidurography performed at the cervical and lumbar regions, codes 62310 and 72275 would be reported for the cervical region, and codes 62311 and 72275 would be reported for the lumbar region.
CPT codes 62310 (cervical or thoracic) and 62311 (lumbar) describe a single injection of a diagnostic or therapeutic substance, not including neurolytic substances, directly into the subarachnoid or epidural space. This type of spinal injection is often described as an interlaminar epidural injection, because of the injection technique being performed directly through the lamina, positioning the needle close to the midline in the back of the epidural space. Due to the positioning of the needle for the injection, this procedure typically cannot be described as unilateral or bilateral, as can other spinal injection procedures. However, epidural injection codes should be reported once per spinal level. Codes 62280 – 62282 describe injection of neurolytic substances, with or without other therapeutic substances, when destruction of a nerve or nerve root is indicated for pain control. For spinal injection procedures performed with no associated diagnostic study, 76005 is also reported. Code 76005 describes the localization of the needle tip to ensure that it is placed exactly into the targeted area of the spine. CPT code 76005 is reported by spinal region and not by spinal level.5 (Code 76005 does not represent a formal contrast study such as those represented by RS&I codes 72240, 72255, 72265, 72270, 72275, 72285, and 72295. Fluoroscopy is considered an inclusive component of these RS&I codes, and code 76005 should not be reported in conjunction with them.)
CPT codes for injections into the paravertebral facet joints or facet nerves are coded with 64470 – 64476, and 64622 – 64627. Facet joint or facet nerve injections are performed as therapy for pain control. The lumbar facet injection codes (64475 and 64476) and cervical/thoracic facet joint injection codes (64470 and 64472) are reported once when the injection procedure is performed regardless of whether single or multiple injections are required at the target level and side.6 These codes are unilateral, and when performed on both sides of the spine, should be reported as a bilateral procedure. Codes 64472 and 64476 are add-on codes, and should be reported for each additional level. Report codes 64622-64627 when a neurolytic agent is injected for destruction of the facet nerve. These are unilateral codes. All of these joint injections are performed under fluoroscopic guidance to avoid damage to surrounding nerve roots or vascular structures, and code 76005 should be reported in addition to these injection codes.
To differentiate technique and code usage, the transforaminal epidural injection codes 64479- 64484 describe both diagnostic and therapeutic nerve root injections that involve needle entry into the epidural space through the intervertebral foramen. This technique differs from interlaminar epidural injection technique (62310- 62311), and from facet joint nerve injection technique (64470-64476), in that it is more difficult to perform. It involves a more lateral approach with the needle right next to the foramen (the bony window where spinal nerves exit the spinal canal), which results in a more localized treatment for a nerve root than the direct, epidural injection provides. The transforaminal epidural injection may often be termed a "nerve block." Like those spinal injection codes described previously, 64479 – 64484 are unilateral codes, and are performed with fluoroscopic guidance. Coding conventions are the same with respect to bilateral injections at the same level, and for add-on codes for additional levels. As well, codes for each level treated are to be reported one time per level regardless of the number of injections performed at that specific level.
Percutaneous vertebroplasty is reported with codes 22520 through 22522 and utilizes imaging guidance (76012 for fluoroscopy, 76013 for CT) to identify a fractured vertebral body, localize the position of the needles to be used for administering the fracture-stabilizing cement, and to monitor the filling of the vertebral body with the cement. This procedure is intended to treat the entire vertebral body, and even though multiple injections may be necessary, the CPT code descriptor states "one vertebral body," and should be reported only once irrespective of whether this is accomplished by unilateral or bilateral injection. Report 22520 if vertebroplasty is performed on a thoracic level, and 22521 for vertebroplasty performed on a lumbar level. Code 22522 should be reported for each additional level, whether thoracic or lumbar, after the first thoracic and/or lumbar levels are coded. Codes 76012 and 76013 are intended to describe the specific image guidance method used, and should be reported once for each vertebral body treated.
Vertebral Augmentation (Kyphoplasty)
New in 2006, CPT codes 22523 – 22525 describe percutaneous kyphoplasty. In this procedure, balloon expansion of the vertebral fracture site is performed prior to injection of the stabilizing cement. Coding conventions for kyphoplasty are the same as for vertebroplasty, in that the thoracic vertebral body code, 22523, and the lumbar vertebral body code, 22524, are reported once each for the initial thoracic or lumbar vertebral body, with 22525 being reported for each additional vertebral body treated. Guidance codes 76012 and 76013 were revised in 2006 to indicate they are to be used with kyphoplasty as well as vertebroplasty.
1 CPT Assistant, November 1999
2 CPT Assistant, September 2004
3 Interventional Radiology Coding User's Guide 2005
4 CPT Assistant, January 2000
5 CPT Assistant, September 2004
6 CPT Assistant, September 2004