August 31, 2013

ACR Radiology Coding Source™ for July-August 2013Q and A

Q: Sacroiliac Joint injection procedure note states "ultrasound was used to identify the sacroiliac region including the posterior superior iliac spine, the sacrum, the sacral hiatus, the sacroiliac ligaments and the iliolumbar ligament bilaterally. Once identifying these structures a 22-gauge needle towards the SI joint was advanced. Once reaching the joint, under ultrasound guidance 5 cc of a combination of 0.25% Marcaine with 6 mg of Betamethasone was injected slowly after a negative aspiration. There was no evidence of intravascular puncture or cerebrospinal fluid or any paraesthesias."Is it appropriate, given this procedure note, to bill CPT code 20610 and 76942 in conjunction with CPT 76881?

A: It is not appropriate to report code 76881 (Ultrasound, extremity, nonvascular, real-time with image documentation; complete) or 76882 (Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific) as the documentation provided in the note above does not support a diagnostic evaluation. The following information can be found on page 398 of the 2013 CPT® codebook, “A complete ultrasound examination of an extremity (76881) consists of real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality.” 
Furthermore, there is no CPT code to describe a sacroiliac joint injection performed with ultrasound guidance, therefore, it is appropriate to report this procedure with code 22899 (Unlisted procedure, spine) and 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation).