X-Ray Coding: Is it the Hip or the Pelvis?

Question:

Can someone please answer the question of if the AP pelvis view is counted as a few when coding hip codes? For example, AP pelvis then 2 individual pictures of each hip AP & Lat; would this be coded as a 73523 (1V pelvis + 2V LT + 2V RT) or would this be coded as 73521 (AP and Lateral Views)? How would you code AP pelvis and 1V of LT Hip? 73501 since it is 1V Hip including AP Pelvis or 73502? There is conflicting information about whether you count the Pelvis as a view and whether you count the individual views done for each side.

Answer:

Thank you for reaching out. If you are performing AP pelvis then 2 individual pictures of each hip AP & Lat; you would code 73523 Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views.  This is consistent with the AMA's Clinical Examples in Radiology guidelines from fall of 2015.

*This response is based on the best information available as of 01/22/26.

Help! Can You Clarify Radiology Documentation Requirements?

Question:

We are just looking for clarification of the Interpretation for Radiology services. We have been including them in our E/M notes for years. Can you please explain exactly what it is payors like UHC are requesting/requiring? Are they wanting a report of that Radiology exam on a separate form altogether?

Answer:

You're not the only one who has been including the interpretation in the E/M.

CPT guidelines in the introductory section of the radiology chapter 70000-79999 states a written report signed by the interpreting individual is considered "an integral part of a radiologic procedure or interpretation." This means radiology interpretation requires formal, separate documentation—not just findings mentioned within an E/M note. The written report must contain interpretive findings and documentation of the imaging performed.

The CPT exception is if the CPT code includes imaging. For example, CPT 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting includes image guidance. Since the imaging is part of the procedure, you document the imaging guidance within your procedure note rather than as a separate radiology report.

This is also consistent with CMS where the payment conditions for radiology services where Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures states: "The interpretation of a diagnostic procedure includes a written report.”

*This response is based on the best information available as of 01/22/26.

Is the ICD-10-CM code enough?

Question:

I am reaching out to ask if a provider lists the ICD-10-CM code with code description on the encounter under the Assessment and Plan if this is sufficient to use as their documentation and would this pass in an audit?

I do not believe this meets the ICD-10-CM guidelines and would like some clarification that I'm not querying erroneously.

Thank you in advance for your response to this matter!

Answer:

Thank you for your query, it is a great question.

No, it is not sufficient for providers to list the code number or select a code number from a list of codes in place of a written diagnostic statement. The AHA coding clinic, specifically the 4th quarter of 2015, states that the ICD-10 codes are "statistical classifications, not replacements for a provider's written diagnosis."

*This response is based on the best information available as of 01/08/26.

Hydrodissection of the Cubital Nerve

Question:

My provider is doing an in office hydrodissection of the cubital nerve. I am only finding a 64999 unlisted code. Is there a better code for this procedure?

Answer:

Selecting the correct code depends upon what and why the procedure is being performed. CPT 64718 requires a neuroplasty and/or transposition of the ulnar nerve at the elbow. If this is not being performed, then 64999 would have to be coded. 

*This response is based on the best information available as of 12/18/25.

Bone Marrow Aspirate

Question:

Good afternoon,
One of our physicians is performing an injection of bone marrow aspirate concentrate into infraspinatus, supraspinatus tendons and the glenohumeral joint, under ultrasound guidance. Bone marrow was aspirated from bilateral iliac crests under US guidance and processed via centrifugation. How should this be reported?
Thank you

Answer:

CPT Category III code 0232T was introduced in 2010 for reporting injection of platelet rich plasma to a targeted site; the code definition includes all harvesting, preparation, and image guidance for the service. In August 2010 the AAOS published guidance in AAOS Now which explained “The new code is to be used only when PRP is performed in a complete separate patient encounter from a surgical procedure.”

Based on this direction, when PRP is injected during another procedure, whether using drawn blood or bone marrow aspirate, it is not separately reportable with the primary surgical service.

If PRP injection is the only service performed, then 0232T is the correct code. In recent years some physicians have begun using bone marrow aspirate harvested from the iliac crest instead of drawn blood for PRP preparation, and reporting the harvesting using CPT code 38220. The May 2012 edition of CPT Assistant clarified that 0232T is the only code reportable for PRP injection, whether performed using drawn blood or harvested bone marrow aspirate. In 2018 the definition of 38220 was changed to reflect that it should be used only for diagnostic bone marrow aspiration. New code 20939 should be used when bone marrow aspiration is performed for bone grafting, for spine surgery only, via a separate incision. CPT instructs to use 20999 for bone grafting, other than spine surgery and other therapeutic musculoskeletal applications.

*This response is based on the best information available as of 12/04/25.

Injections and E/M Visits

Question:

How do you code for an unplanned injection as well as the E&M service necessary to make the decision to perform the injection?

Answer:

The answer to this question depends upon if you are providing a significant and separate evaluation and management service in addition to an injection, and not whether the injection was planned or unplanned.  Every minor procedure has time for pre-service evaluation included in the value of the procedure code. Medicare and other payors have become concerned that E/M’s are being routinely reported with minor procedures without considering if the extent of the visit was truly more than the pre-service evaluation already included in the procedure. Just because an injection is unplanned does not automatically allow for an E/M visit to be billed. There must be a significant and separately identifiable E/M service above and beyond the injection. Please listen to our KZA KAST Modifier Monday podcast on Modifier 25 for additional information.

https://monday.transistor.fm/

*This response is based on the best information available as of 11/20/25.