Standard procedure for CPT code for Myelogram
Myelography uses a real-time form of x-ray called fluoroscopy and an injection of contrast material to evaluate the spinal cord, nerve roots and spinal lining (meninges). Myelogram is done to examine the spinal cord and nerves that come out of the spinal cord to look at spinal and disc problems. In this procedure, puncture is made into the thecal sac with a spinal needle and a water-soluble contrast agent or a dye is injected into the sac. Contrast medium is used in medical X-ray imaging to show the inside of the body on an image or picture. This exam is called as Myelogram. A puncture of the thecal sac is called a lumbar puncture. Having a clear knowledge of such procedures helps a lot for medical coder to prepare and clear CPC exam.We have separate CPT codes for Myelogram for all the levels of spinal cord.
Sample Chart for CPT codes for Myelogram
In coding, we have some rules to follow to code procedure codes for Myelogram. For example, we are not supposed to code the Myelogram procedure until and unless the complete myelographic procedure is done with full radiological Supervision and interpretation (S&I). Coding for S & I CPT code is little complicated for coder, but it is not as difficult. See the below example about Lumbar myelogram.
Indication: Low Back Pain
Informed consent was obtained. The patient was cleaned and prepped in the usual sterile fashion. After injecting local anesthetic, a 20 g needle was advanced and entered into the thecal sac at L3 level. Clear CSF returned 15 cc Omnipaque-180 s injected intrathecally under fluoroscopy and myelogram was performed. The procedure was tolerated well and there were no complications.
Findings: The vertebral body height and alignment is well-maintained. The thecal sac is well filled with contrast. L4-L5 disc space is diminished indicated of degenerative changes noted.
IMPRESSION: A lumbar myelogram was performed. The degenerative changes at L4-L5 level. Please refer to CT study of lumbar spine for further details.
CPT code: 62304
If you see in the above chart, we have a technique that clearly documents the injection of contrast into the thecal sac and myelogram is performed. Now, immediately the physician documents the findings, which means he has done both injection and interpreted the results. Hence, in such cases we have to code myelogram CPT Code along with Supervision and interpretation CPT codes. Here, we have coded as combined CPT code for injection and S&I CPT code for Lumbar Myelogram procedure (62304).
Now, if you assume that the finding were not documented, then in such scenario we will go with fluoroscopy CPT code 77002 along with injection CPT code. Then the procedure codes will be 62284 and 77002. Do remember Fluoroscopy is included with S&I codes and hence should not be coded together.
Different CPT codes for Myelogram
We have separate CPT code for lumbar and cervical myelogram. Similarly, we have separate radiology myelography CPT Codes for both. We should never forget to code Supervision and interpretation CPT codes or guidance codes along with myelogram procedure codes. We have separate and combined codes for myelogram. Combined CPT codes include S&I CPT codes while there are separate CPT codes when only injection procedure is performed. First, we will check the injection procedures for lumbar and cervical region.
62284 – Injection procedure for myelography and/or computed tomography, lumbar
61055 – Injection procedure at C1-C2
The above CPT codes are used when only an injection is performed in spinal region.
Combined CPT codes for Myelogram
62302 – Myelography via lumbar injection, including radiological supervision and interpretation; cervical
(72240 Myelography, cervical, radiological supervision and interpretation)
62303 – Myelography via lumbar injection, including radiological supervision and interpretation; thoracic
(72255 Myelography, thoracic, radiological supervision and interpretation)
62304 -Myelography via lumbar injection, including radiological supervision and interpretation; Lumbosacral
(72265 – Myelography, lumbosacral, radiological supervision and interpretation)
62305 – Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical)
The above CPT codes includes the below radiological supervision and interpretation CPT codes.
Do and Don’t for CPT codes for Myelogram
Do not code 62284 along with 62302, 62303, 62304, 62305, 72240, 72255, 72265, and 72270.
Do code 62302, 62303, 62304, 62305 when both injection (62284 or 61055) and S &I (72240, 72255, 72265, 72270) are performed.
Do not report S&I CPT codes 72240, 72255, 72265 and 72270 along with 62284, 62302, 62303, 62304, 62305.
Do not code Fluoroscopy CPT code 77002 along with S&I CPT codes. Fluoroscopy is always included with S&I CPT codes.