AMA Clinical Examples in Radiology - 2014 Issue 4 (Fall)
Lumbar Myelogram and CT Lumbar Spine Post-Myelogram
CLINICAL EXAMPLE 2 Lumbar Myelogram and CT Lumbar Spine Post-Myelogram CLINICAL HISTORY Bilateral hip pain and right leg pain. Patient unable to undergo magnetic resonance imaging (MRI) scan. Prior laminectomies. Clinical concern for positional spinal stenosis. PROCEDURE Lumbar myelogram. TECHNIQUE 62304 The risks, benefits, and alternatives to the procedure were discussed with the patient who agreed to proceed. With the patient in the prone position, the L3-L4 level was localized under fluoroscopic guidance. Overlying skin was marked and prepped, and the patient was draped. A surgical "time-out" was performed. Skin and subcutaneous tissues were anesthetized with 1% lidocaine. A...
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Article Overview
This premium article explains how a lumbar myelogram and a follow-up lumbar CT after myelography are documented and reported. It also covers the broader CPT myelography bundle update, related spinal-region reporting concepts, PQRS fluoroscopy reporting, and NCCI modifier-related considerations. It is aimed at coders, billers, and radiology professionals who need to understand how the service is described in the context of 2015 coding changes and quality reporting.
Why This Topic Matters
Imaging services that combine myelography and CT often involve multiple code sets, bundled reporting concepts, and quality-reporting requirements. Understanding the article helps readers determine whether they need guidance on lumbar spine myelography, post-myelogram CT reporting, fluoroscopy documentation, or related modifier and edit issues.
Article Sections
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Clinical Example 2
Introduces the case example and the imaging workflow for a lumbar spine study. Includes the clinical context and the sequence of procedures described in the report.
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CT Lumbar Spine with Contrast
Presents the associated post-myelogram CT portion of the example. Summarizes the imaging context, technique, and reported findings for the lumbar spine examination.
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How to Code
Provides the article’s coding-oriented summary for the reported services. Highlights the reporting framework used for the myelogram, CT, and fluoroscopy documentation.
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Discussion
Reviews myelography as a diagnostic modality and explains the broader coding and reporting context. Covers bundled myelography reporting, spinal-region concepts, quality reporting, and related edit considerations.
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Coding tip
Notes a special reporting scenario involving a less common approach to myelography. Discusses the relationship between the injection service and region-specific reporting in that context.
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Sources
Lists the reference materials cited by the article. Identifies the general publications and organizations supporting the discussion.
What You Will Learn
- How a lumbar myelogram and post-myelogram lumbar CT are discussed in a coding context
- How bundled myelography reporting is addressed for spinal-region services
- How fluoroscopy documentation is tied to quality reporting references
- How related modifier and edit concepts are discussed in relation to myelography and CT reporting
Who Should Read This
- Medical coders
- Radiology coders
- Billing staff
- Physician practices
- Radiology departments
- Compliance staff
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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