blind injectionWhat’s Up With Guidance?

We have been monitoring carrier changes with respect to the use of “guidance” with various injection procedures.  As we look at the 2014 PFS look-up tools we see  that code 76942 (ultrasound guidance for needle placement) has taken a dramatic cut in reimbursement with the Medicare reimbursement for 2014 set around $70.00, down from around $200.00 in 2013.

This code has been a target of Medicare for quite a while having been deemed both over valued and over used by practitioners.  The first step against the code was to assign it to those codes subject to the multiple procedure payment reduction list.  This reduced the payment to practitioners to 100% of the first procedure and only 50% on subsequent procedures.

Next, Medicare and others declared “injection guidance” procedures were limited to one (1) per day regardless of the number of injection type procedures performed.  Now, they have retained that position for now but reduced the value of the code.

There is no AMA CPT coding restriction to reporting CPT code 76942 (Ultrasonic guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation) when ultrasound guidance is medically necessary to accurately place the needle for the injection. Carriers however, feel in most cases, imaging guidance to penetrate an easily palpable joint seems neither reasonable nor necessary.

CPT code 76942 has both professional and technical components, meaning that a separate radiology report (not part of the procedure note) is required to meet the code’s radiology requirements. The specific documentation requirements for ultrasound guidance include the following:

  • A final, written report should be issued for inclusion in the patient’s medical record.
  • Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.
  • Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.


Other carriers are mounting challenges based on the “performing provider” charging that “interpretation” of the imaging is outside the scope of NPPs.

Although reporting code 76942 with the joint injection code 20610 is permissible, many payers are denying this service as not medically necessary. For example, under the Florida First Coast Medicare local coverage determination (LCD) 29307, “Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.”

Other Medicare carriers, such as National Government Services, have initiated payment recovery for CPT code 76942 on the basis of lack of medical necessity as well as recouping amounts paid for multiple procedures when only one unit was payable.  We have seen similar actions by other carriers.

On the flip side, code 77002 for fluoroscopic guidance has been increased from around $74 to $96 for this fee schedule BUT we now seeing various restricting tactics on these procedures by NPP’s as well.

Carriers such as NGS also challenged fluoroscopic guidance when performed by nonphysician practitioners.  In specific NGS invoked “in compliance with State laws” as part of their recovery tactics. We joined others in challenging this since it is NOT true in all States within their jurisdiction.

When questioned they did post the “specifics” for J6 Part B for the States of Illinois, Minnesota and Wisconsin…….and we published their answers in our MedCorp Alert.

“We have finally received specific answers from NGS on covered nonphysician practitioner radiology services within the J6 Part B for the states of Illinois, Minnesota, and Wisconsin.

Which nonphysician practitioners may use fluoroscopy or ionizing radiation?

  • Certified Registered Nurse Anesthetist (Specialty 43) –  NO in all three states.
  • Certified Nurse Midwife (Specialty 42 NO in all three states
  • Clinical Nurse Specialist (Specialty 89)-   NO in all three states.
  • Nurse Practitioner (Specialty 50)-    Illinois and Minnesota:  NO
    • Wisconsin:  YES, according to Wisconsin Administrative Code § DHS 157.03 and 157.76
  • Physician Assistant (Specialty 97)-    Illinois:  NO
    • Minnesota:  YES, according to Minnesota Rules 2007, Chapter 4732
    • Wisconsin:  YES, according to Wisconsin Administrative Code § DHS 157.03 and 157.76

Which nonphysician practitioners may provide supervision of radiology procedures?

Supervision of others by NPPs is NOT permitted in Illinois, Minnesota, or Wisconsin or under Medicare.

 Which nonphysician practitioners may bill for the technical component?

  • Certified Registered Nurse Anesthetist (Specialty 43) NO in all three states.
  • Certified Nurse Midwife (Specialty 42) NO in all three states.
  • Clinical Nurse Specialist (Specialty 89) NO in all three states.
  • Nurse Practitioner (Specialty 50)NO in Illinois and Minnesota.
  • o          Wisconsin:  YES, only if personally performed
  • Physician Assistant (Specialty 97)  NO in Illinois
  • o          Minnesota and Wisconsin:  YES, only if personally performed.

Which nonphysician practitioners may bill for the professional component?


  • All three States permit the professional component by Certified Registered Nurse Anesthetist (Specialty 43); Certified Nurse Midwife (Specialty 42);Clinical Nurse Specialist (Specialty 89); Nurse Practitioner (Specialty 50) and PA (Specialty 97)

Which NPPs may bill for global if the technical component is personally performed?

  • Certified Registered Nurse Anesthetist (CRNA) (Specialty 43) NO in all three states.
  • Certified Nurse Midwife (Specialty 42) NO in all three states
  • Clinical Nurse Specialist (Specialty 89) NO in Illinois and Minnesota.
    • Wisconsin:  YES
  • Nurse Practitioner (Specialty 50);  NO in Illinois and Minnesota:
    • Wisconsin:  YES
  • Physician Assistant (Specialty 97)  NO in  Illinois
    • Minnesota and Wisconsin:  YES


While we have some “permissions” in some instances, CMS still essentially prohibits NPP performance under their required physician supervision level for the technical component of Fluoroscopic guidance codes as being level “03” which requires procedure must be performed under the personal supervision of a physician.”   This applies to

  • 77001-TC Fluoroguide for vein device;
  • 77002-TC Needle localization by xray –
  • 77003-TC Fluoroguide for spine inject

and would naturally extend to the procedures such as the 6449x facet joint injections that “require” either Fluroscopic or CT guidance.

 To “double check” the “actual enforcement” of these levels, I contacted the specific contacts in CMS for these issues.   Our exchange is below….

Dear Mr. Chan:

I am writing in regards to the reclassification of CPT codes 77001-77003  technical component of fluoroscopic guidance to “3” requiring personal supervision of the physician.  This would appear to again preclude the use of NP/PA “personal performance” and/or the use of certified radiology technicians who have previously been permitted to operate the C-Arms under the general supervision of the physician.

Can you please provide us with the “specifics” on the fluoroscopic guidance procedures (who can and who can’t perform) so we can provide the proper guidance to our members as they call us with these questions.  We are already getting quite a few calls based on the various June 2014 Medicare Advisory publication which is considerably lacking in details on this matter.


Dear Dr. Ramsdell,

 Thank you for your email and your voice message concerning the technical component for CPT codes 77001 – 77003.  In our April 2014 update to the Physician Fee Schedule, we corrected an inadvertent technical error to the files as displayed for January 1, 2014.  In the January files, a “09” code (“Concept does not apply”) was inadvertently entered into the Physician Supervision of Diagnostic Procedures indicator for CPT codes 77001 – 77003.  Previously the indicator for these codes was “03” (“Procedure must be performed under the personal supervision of a Physician”).  The April update corrected the data file to reflect the established policies.  Please see section 100.1.5, from Chapter 12 of the internet only claims manual (available at, and 42 CFR 410.32(b)(1) for specific guidance regarding physician supervision.

 I hope this clarifies any confusion.

Larry Chan

 [RLR]Thank you for your reply.  So if I am interpreting this correctly, the “physician” must be in the room when either a mid-level or a rad-tech operates the fluoroscope for guidance of the injection?   This is the question we keep getting hit with and keep trying to get the specific yes or no on.   We understand that the mid-level can not supervise the rad-tech.

{LC} You are correct.  The supervision for the TC of these CPT code is “03” (“Procedure must be performed under the personal supervision of a Physician”).  The Physician is to be present in the room with the tech.

These positions make it virtually impossible for a mid-level to perform injections that require guidance including those procedures where “fluoroscopic / CT guidance” is required and if the physician is required to be in the room, the economics would appear to be logically for him/her to perform the injection procedure in its entirety.

We would like your comments on this AND your assistance by writing or contacting HHS/CMS and your local Medical Association.