Ask Dr. Z

During a shoulder arthrogram, I understand that you report code 73040 if images were taken before and after injection. If only spot films were taken, you would use code 77002. Can you tell me if it matters what kind of images were taken? I am including a clean copy of the report for your review. "Exam: Right shoulder arthrogram. History: Right pain since October. History of prior rotator cuff tear. Scout images of the right shoulder were obtained. An appropriate site for skin entry was chosen, marked, prepped, draped, and anesthetized in the usual sterile fashion. The right shoulder joint was entered using a 22 gauge spinal needle and 9 mL of the standard mixture of non-iconic intravenous contrast and gadolinum were injected. The needle was withdrawn, bandaid applied, and no complications were noted. Contrast is suspected in the subacromial/subdeltoid bursa, and the appearance is certainly worrisome for and compatible with rotator cuff tear. 3.5 minutes of total fluoroscopy time was used. The patient was sent to ME in stable and satisfactory condition."