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 February 2013 Coding Q and A

By, Mary LeGrand, RN, MA, CCS-P, CPC, Consultant and Speaker
KarenZupko & Associates, Inc.

Office Fluoroscopy 

When can fluoroscopy be reported in the office?  Is it acceptable to bill one hour of fluoroscopy when performing an injection?
Fluoroscopy is a study of motion.  CPT code 76000 Fluoroscopy (separate procedure), up to one hour physician time, is considered inclusive to musculoskeletal procedures and is reported when appropriate for surgeries performed in an operative suite.
If the surgeon uses fluoroscopy for the purpose of needle localization for a joint  or tendon injection in the office, the correct code is 77002, Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device).
In the office setting, CPT code 77002 is reported in addition to the injection code. Documentation must include medical necessity, identification of structures viewed, and localization of site of drug administration.  A separate radiology report is required to support reporting the global radiology code.

Modifier 22

When is it appropriate to append modifier 22 to a surgical CPT code?
Modifier 22, Increased Procedural Service is appended to a surgical CPT code when the procedure performed is significantly more complex than the average procedure performed for a defined CPT code.  Codes have a range of complexity, so before a modifier 22 is appended, there should be documentation of significant, increased work. A third revision carpal tunnel release is a good example. CPT code 64721 is valued for a primary carpal tunnel release. 
When the patient requires a third revision, the procedure may have increased difficulty related to significant tenosynovitis. The flexor tenosynovectomy is included in the CPT code 64721 and is not separately reportable.  The additional work, complexity and time associated with the tenosynovectomy related to this third revision supports adding the modifier 22 to CPT code 64721.
The Global Service Data Guide assists in accurately reporting the revision. The following services are considered inclusive to CPT code 64721:
​11. division of transverse carpal ligament, with or without Z-plasty or other local tissue rearrangement (eg, 25020)
​12. ​tenosynovectomy/tenolysis of flexor tendon(s) (eg, 25110, 25115, 25295)
​13. ​excision of lipoma of carpal canal (eg, 25075)
​14. ​incidental release of ulnar nerve (eg, 64719)
​15. ​endoscopic release of transverse carpal ligament (eg, 29848)

Endoscopic Cubital Tunnel Surgery

Endoscopic Cubital Tunnel procedures have been around for some time now.  Why has a CPT code for this procedure not yet been named? 
There are many factors considered for the creation of new CPT codes.  One is the demonstrated need for the new code.  Reporting the CPT code with the unlisted code, 29999 and identifying on the claim form that the unlisted code represents the endoscopic approach will initiate utilization patterns that may be used to assess the need for a new code.   Submit a request to the ASSH for a new code consideration.    Additional information on applying for a new code may be found at

Fasciotomy and Endoscopic Carpal Tunnel Release

When can a hand surgeon report CPT code 25020 in addition to 29848 for an endoscopic carpal tunnel when performing a separate dedicated portion of the procedure to dividing the forearm fascia up to 4 cm through the proximal endoscopic wrist incision?
CPT code 25020 defines a decompressive fasciotomy for compartment syndrome.  Releasing the distal antebrachial fascia is not separately reportable with CPT code 29848. 

The following questions were submitted following the 2012 Coding Webinar. This article was reviewed and approved by: Daniel J. Nagle MD. Chair ASSH Coding and Physician Reimbursement Committee