FLUOROSCOPY IN THEHOSPITAL SETTING

Int roduct ion

Fluoroscopic imaging guidance is an integral component of many surgical and interventional procedures in the hospital setting. Imaging guidance provides real-time visualization of anatomical structures and can aid in the accurate placement of devices, reduce complications, and improve patient outcomes However, it is essential that the coding and reporting of fluoroscopy comply with Medicare guidelines to avoid potential errors and financial penalties

Medicare, the largest payer of healthcare services in the United States, has specific guidelines that govern coding and billing for both fluoroscopic and ultrasound imaging guidance The use of these modalities in conjunction with surgical and interventional procedures requires careful attention to ensure compliance with Medicare's rules and regulations.

It is important to note that fluoroscopic guidance (specifically CPT® 76000) is inclusive to many surgical and interventional procedures, as discussed below Some code pairs will have specific National Correct Coding Initiative (NCCI) PTPedits (as shown below) and some may not, but the National Correct CodingInitiative(NCCI) PolicyManual nonetheless prohibits fluoroscopy from being reported in conjunction with certain types of procedures

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Fluoroscopy In Thehospital Setting

Fluoroscopic Guidance

Fluoroscopy is a type of imaging that uses x-raysto provide real-time visualization of anatomicalstructures during a surgical or interventional procedure. Medicare has specific guidelines for coding and billing for procedures that use fluoroscopic guidance. The following are some of the nuances of correct and compliant coding for fluoroscopy in the hospital setting

Accurate and complete documentation is critical when billing for fluoroscopic guidance. The documentation should clearly indicate the type of procedure, the number of images taken (if applicable), the duration of the procedure, and the specific anatomical location of the images This information is essential to ensure that the service is accurately reported

Cent ral Venous Access

According to the NCCI Policy Manual, Chapter 1, insertion of central venous access devices frequently requires the use of fluoroscopic guidance: ?Since CPT® code 77001 describes fluoroscopic guidance for central venous access device procedures, CPT® codes for more general fluoroscopy (e g , 76000, 77002) shall not be reported separately (CPT® code 76001 was deleted January 1, 2019.)?

Endoscopic Procedures

Fluoroscopy is also considered integral to all endoscopic procedures, including (but not limited to) laparoscopy, hysteroscopy, thoracoscopy, arthroscopy, esophagoscopy, colonoscopy, other GI endoscopy, laryngoscopy, bronchoscopy, and cystourethroscopy & transurethral procedures It should not be reported separately with any endoscopic procedure. CPT® Assistant (September 2014) reiterates this advice. For example, CPT® code 76000 is not separately reportable with codes describing gastrointestinal endoscopy for foreign body removal (e g , 43194, 43215, 43247, 44390, 45332, 45379)

Laparoscopic Procedures

Fluoroscopy is considered inclusive to all laparoscopic procedures and should not be reported separately.

Fluoroscopy In Thehospital Setting

Art hroscopic Procedures

Likewise, CPT® 76000 is considered an integral component of arthroscopic procedures, when performed, and should not be reported separately with any arthroscopic procedure.

Spinal Procedures

Chapter 3 of the NCCI Policy Manual states, ?Fluoroscopy reported as CPT® code 76000 shall not be reported with spinal procedures, unless there is a specific CPT® Manual instruction indicating that it is separately reportable For some spinal procedures, there are specific radiologic guidance codes to report in lieu of these fluoroscopy codes.

For other spinal procedures, fluoroscopy is used in lieu of a more traditional intraoperative radiologic examination which is included in the operative procedure For other spinal procedure codes, fluoroscopy is integral to the procedure.? The May 2016 issue of CPT® Assistant reiterates this guidance.

For example, codes 62321, 62323, 62325, and 62327 represent injections of diagnostic or therapeutic substance(s) into the epidural or subarachnoid spaces at different spinal levels with either fluoroscopic or CTguidance Imaging guidance is included in these procedures and should not be reported separately

Cardiovascular Procedures

Fluoroscopic guidance is included in codes relating to cardiac catheterization and percutaneous coronary artery interventional procedures. Fluoroscopy is also not separately reportable with procedures related to pacemakers or intracardiac electrophysiology studies (represented by CPT® codes 33202-33275 and 93600- 93662, respectively) Fluoroscopy codes intended for other specific procedures may be reported separately when applicable. Additionally, ultrasound guidance is not separately reportable with these CPT® codes.

Internal cardioversion is performed using percutaneous vascular access and placement of one or more catheters into the heart under fluoroscopy. Fluoroscopic guidance is included and is not reported separately. Fluoroscopy codes (e.g., CPT® code 76000) are not separately reportable for endomyocardial biopsy

Codes Inclusive Of Radiologic/ Im aging Guidance

According to the NCCI Policy Manual, ?If the code descriptor for a HCPCS/CPT® code, CPT® Manual instruction for a code, or CMSinstruction for a code indicates that the procedure includes radiologic guidance, a provider/supplier shall not separately report a HCPCS/CPT® code for radiologic guidance including, but not limited to, fluoroscopy, ultrasound, computed tomography, or magnetic resonance imaging codes

If the physician performs an additional procedure on the same date of service for which a radiologic guidance or imaging code may be separately reported, the radiologic guidance or imaging code appropriate for that additional procedure may be reported separately with an NCCI PTP-associated modifier if appropriate.?

Diagnost ic and Int ervent ional Radiologic Procedures

Fluoroscopy is included in most radiological supervision and interpretation (RS&I) procedures Unless otherwise stated, NCCI policy states ?fluoroscopy necessary to complete a radiologic procedure and obtain the necessary permanent radiographic record is included in the radiologic procedure and shall not be reported separately.?Fluoroscopic guidance is considered integral to diagnostic and therapeutic intravascular procedures and is not separately reportable

Both CPT® and NCCI instruct that diagnostic angiography (arteriogram/venogram) performed on the same date of service by the same provider/supplier as a vascular interventional procedure should be reported with either modifier 59 or XU If a diagnostic angiography has already been performed before a percutaneous intravascular interventional procedure, then a second angiogram cannot be reported unless it is medically necessary to further examine the anatomy and pathology

If a repeat angiogram is required, it should be reported with a modifier 59 or XU However, if only a portion of the angiogram needs to be repeated, then a modifier 52 should also be appended to the angiogram CPT® code along with modifier 59 or XU It is important to note that if a complete diagnostic angiogram has already previously been performed, then a second angiogram should not be reported for the contrast injections necessary for the percutaneous intravascular interventional procedure, except in certain specific circumstances.