Coder's Guide to Epidurogram (CPT 72275)

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By AMA standards, an epidurogram is more than visualizing the contrast flow in the spine during and/or after an injection; it's a diagnostic study to be used to aid the physician in finding a reason for what may be causing pain in the spine that may be missed by other imaging methods (CT/MRI). It's designed to be a help in deciding further treatment for the patient. Because it's not meant to be a routine procedure, it's not expected to see these done all the time in conjunction with epidural injections.

Physicians could be potentially losing out on revenue by not documenting what they're actually already seeing, thinking and doing. Many of the requirements needed to code and bill for the epidurogram (CPT 72275) are found in the providing physician's decision-making processes, but are not documented and so only the fluoroscopy (77003) can be reported.

In New Jersey, per Medicare's fee schedule, payment for epidurogram is $121.37 while for fluoroscopy alone (77003), the payment is $68.54 in an office setting. This represents a loss of nearly 44 percent each time an epidurogram is performed but can't be reported per the coding rules.

Per AMA's CPT Assistant, there are certain elements that should be documented that go beyond the flow of the contrast in order for the physician to correctly report 72275. These elements should be written in a report that is separately distinguishable from the epidural injection results and subsequent results. Without these elements, only the fluoroscopic part of the procedure (77003) can be reported.

Based on what CPT Assistants guidelines say that these reports should include, below is a checklist with these elements to assist physicians and coders to determine whether or not to bill 72275.

Epidurogram (72275)

_______ Diagnostic epidurogram performed, supervised and interpreted

_______ A formal radiologic report is prepared separated from the injection procedure(s)

_______ A diagnostic evaluation following an injection of contrast

_______ Permanent "hardcopy" images in multiple planes of a specific anatomic region (i.e., cervical, thoracic, lumbar) are placed in the patient's record and kept on file

_______ The degree of fluid flow (or lack thereof) in the epidural space is obtained and documented

_______ Area(s) of scarring, nerve constriction, possible nerve inflammation (obstructions) in the epidural space are/are not seen and documented

_______ Epidurographic findings aid in evaluating potential treatment options

Note: A PDF form of the checklist above can be found by clicking here.

To further assist physicians and coders, below are some examples of billable epidurograms, based on the above checklist.

Example #1: Epidurogram — diagnostic study (72275)

Procedure: Intraoperative lumbar epidurography

The patient underwent lumbar epidural steroid injection today with hard-copies on file. The intervertebral space L4-L5 and L5-S1 were viewed using AP and lateral projection and negative contrast technique. Moderate degenerative changes intervertebral space L4-L5 and L5-S1 with decreased height at least 40 percent. Bone anterior and some posterior bony spurs and moderate degree endplates degeneration noted. No leakage of contrast through the disc membrane identified. Anterior epidural spread of the contrast appeared to be normal as well as in AP projection where the contrast spread to both sides of the epidural space.

Conclusion: Moderate degenerative changes intervertebral space on the level L4-L5 and L5-S1 with posterior disc prolapse impinging vertebral sac.

Epidurogram (72275)

___ Y___ Diagnostic epidurogram performed, supervised & interpreted

___ Y___ A formal radiologic report is prepared separated from the injection procedure(s)

___ Y___ Diagnostic evaluation following an injection of contrast

___ Y___ Permanent "hardcopy" images in multiple planes of a specific anatomic region (i.e., cervical, thoracic, lumbar) are placed in the patient's record & kept

___ Y___ The degree of fluid flow (or lack thereof) in the epidural space is obtained and documented

___ Y___ Areas of scarring, nerve constriction, possible nerve inflammation (obstructions) in the epidural space are/are not seen and documented

Example #2 – Epidurogram — diagnostic study (72275)

Description of procedure: The patient underwent lumbar epidural steroid injection today. The epidural was observed at the level of L4-L5 under AP and lateral fluoroscopic guidance. 2cc of Omnipaque 240 contrast was injected that evenly spread from level L3 to S1 level with posterior-anterior dye spread bilaterally at level of L4-L5 and L5-S1. There appeared to be a moderate degree spondylosis at level of L4-L5 and moderate degree of spondylosis at the level of L5-S1 with disc protrusion at the level of L4-L5. The intervertebral disc height at the level of L4-L5 was slightly less than normal and intervertebral disc height at the level of L5-S1 was well maintained. The neural foramen appeared to be patent.

Conclusion:

Good epidural dye containment from L3-S1 with intervertebral disc protrusion at the level of L4-L5, maintaining less than normal intervertebral disc height at level L4-L5. Spondylosis noted at the level of L4 through S1. Hard copies of the images are on file.

Epidurogram (72275)

___ Y___ Diagnostic epidurogram performed, supervised and interpreted

___ Y___ A formal radiologic report is prepared separated from the injection procedure(s)

___ Y___ Diagnostic evaluation following an injection of contrast

___ Y___ Permanent "hardcopy" images in multiple planes of a specific anatomic region (i.e., cervical, thoracic, lumbar) are placed in the patient's record and kept

___ Y___ The degree of fluid flow (or lack thereof) in the epidural space is obtained and documented

___ Y___ Areas of scarring, nerve constriction, possible nerve inflammation (obstructions) in the epidural space are/are not seen and documented

References:

- CPT Assistant (AMA) 10/2009, 7/2008, 8/2000

- "Coding of Diagnostic and Therapeutic Spinal Procedures," ACR Radiology Coding Source, March-April, 2006