The appropriate code to describe this procedure is 78630 (Cerebrospinal fluid flow, imaging [not including introduction of material]; cisternography) for the radiological side. Depending on site of the puncture, one of the following injection codes would apply:
62310 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
62311 ... lumbar, sacral (caudal). Since your dictation specifies injection into the subarachnoid space, this procedure should resolve with 62310. You can charge for fluoroscopy only if the radiologist does not read the cisternogram. If you charge the RS&I (radiological supervision and interpretation), you can't charge the fluoroscopic guidance because it is included in RS&I. Reader Questions and You Be the Coder were answered by Gary Dorfman, MD, FACR, SIR, president of Health Care Value Systems in North Kingstown, R.I.; Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., an Atlanta-based firm; and Phillip C. Seeger BS, RT(R), of Lakeland Regional Health System Radiology Department in St. Joseph, Mich.