Fluoroscopic guidance for needle placement usually documented in the operative report

Q.

Does CPT^® code 77002 require a separate radiologist interpretation when it is performed in the operating room? 

A.

CPT code 77002 is an “imaging guidance” code. 

The code and full description are as follows:

77002    Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)

Imaging guidance codes require documentation of the process in the medical record, but it is usually in the operative report as described by the surgeon. A separate interpretation by a radiologist is not necessary (unless your state law requires it, or your hospital guidelines do). These codes do require permanent imaging as well as the description of the imaging procedure. Most, such as CPT code 77002, are also limited relative to the codes they may be used with. If these requirements are met, the hospital may report 77002. As CPT defines this code as an “add-on” (see the “+” sign preceding the code) code, it is not paid separately by Medicare under OPPS, but may be reimbursed by other non-Medicare payors.