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Find out when you need a guidance code.

Knowing how and when to report image guidance procedure codes requires careful examination of guidelines, instructional notes, and descriptors. Revenue Cycle Insider put together a quiz to test your knowledge of image guidance coding.

Read through the following scenarios and check your answers at the bottom of the article.

Scenario 1: A physician orders fluoroscopic guidance during an anesthesia injection into the mandibular branch of the patient鈥檚 trigeminal nerve.

What code(s) will you assign to report this procedure?

1. 64400, +77001
2. 64400, +77002
3. 64400, +77003
4. 64400

Scenario 2: A physician collects tissue percutaneously from a lesion on the patient鈥檚 left breast, right upper quadrant. The provider uses ultrasound (US) guidance during the procedure.

What code(s) will you assign to report this procedure?

1. 19081
2. 19083
3. 19085
4. 19100, 76942

Scenario 3: A patient presents with a malignant liver tumor that is not suitable for surgical removal due to its location. The provider decides to use parenchymal tissue ablation guided by magnetic resonance imaging (MRI). The provider uses the MRI to accurately guide the ablation device to the tumor and monitor the ablation process in real-time, ensuring that the entire tumor is treated while minimizing damage to the surrounding healthy tissue.

What code(s) will you assign for the image guidance?

1. 20982, 77013
2. 77021
3. 77022
4. 20982, 77014

Answer 1: Identify the Image Guidance Needed for an Injection

You need two CPT^庐 codes to report the anesthesia injection with fluoroscopic guidance. You鈥檒l first assign 64400 (Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)) to report the physician鈥檚 anesthesia injection into the mandibular branch of the trigeminal nerve.

Next, you鈥檒l want to examine the three different fluoroscopic guidance add-on codes, which are as follows:

• +77001 (Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure))
• +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure))
• +77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure))

Each of these codes must be reported with a primary procedure code and cannot be billed alone. Knowing which primary procedure code to use with +77001, +77002, and +77003 is important because the add-on codes can only be used with certain procedures.

For example, 鈥淎dd-on code +77001 can only be used with central venous access placement per the descriptor. So, one of the most common uses of +77001 is when a tunneled central venous catheter with port is placed using fluoroscopy,鈥� says Maia Karpenske, CPC, CIRCC, interventional radiology coder at Tennessee Interventional Imaging Associates in Chattanooga, Tennessee.

At the same time, +77002 features a parenthetical note instructing you to use the add-on code with specific codes 鈥� such as 64400. This backs up the scenario presented where the provider used the fluoroscopic guidance to place the anesthesia needle for injection into the correct nerve.

Therefore, the correct answer is b. 64400, +77002.

Answer 2: Know if Image Guidance Is Included

Simply put, if a procedure code descriptor features the wording 鈥渋ncluding imaging guidance,鈥� 鈥渨ith [type of] guidance,鈥� or 鈥渋ncludes image guidance when performed,鈥� then you鈥檒l report just the procedure code. The wording means the image guidance is inherently included in the procedure, regardless of whether the provider uses the service.

In the scenario, the physician used US guidance to collect breast tissue percutaneously. The CPT^庐 code book features three primary procedure codes for breast biopsy procedures:

• 19081 (Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance)
• 19083 (鈥� first lesion, including ultrasound guidance)
• 19085 (鈥� first lesion, including magnetic resonance guidance)

The difference between the codes is the equipment used for the guidance. Since the provider used US guidance during the procedure, the correct answer is b. 19083.

Answer 3: Master When MRI Guidance Applies

The scenario presented specifically called out the use of MRI guidance during the parenchymal tissue ablation. This knowledge eliminates answers A and D because 77013 (Computed tomography guidance for, and monitoring of, parenchymal tissue ablation) and 77014 (Computed tomography guidance for placement of radiation therapy fields) are designated for computed tomography (CT) guidance.

That leaves choices b. and c., which feature the following codes:

• b. 77021 (Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation)
• c. 77022 (Magnetic resonance imaging guidance for, and monitoring of, parenchymal tissue ablation)

You鈥檒l assign 77021 when the MRI guidance is used for needle placement. On the other hand, 77022 specifies 鈥渇or, and monitoring of, parenchymal tissue ablation鈥� in the descriptor. Parenchymal tissues are an organ鈥檚 or growth鈥檚 functional tissue. Of course, when properly reporting the encounter, the guidance should be performed along with an appropriate ablation code.

However, in this case, the correct answer is c. 77022.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC