The
next time you code an epidural steroid injection (ESI), take a
closer look at your claim. You could be losing up to $86 if you miss an
opportunity to report fluoroscopy code 77003.
Use
this comprehensive look at coding pain management ESI
encounters to be sure you’re getting every dime you deserve.
Start
With 62310-62311
The
physician likely will choose an interlaminar epidural
approach, placing the medicine inside the epidural space. “As long as
the needle
is positioned in the epidural or subarachnoid space with the needle
[inserted]
‘straight’ in between the lamina,” then the following are the correct
codes,
says Julee Shiley, CPC, CCS-P, CMC, in Raleigh, N.C.:
•
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).
Pay
attention:
Be careful not to confuse
single injection codes 62310-62311 with the following continuous
infusion or
intermittent bolus codes:
•
62318 -- Injection, including catheter placement, continuous
infusion or intermittent bolus, 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
•
62319 -- … lumbar, sacral (caudal).
Watch
for Transforaminal Approach
If
the physician inserts the needle at an angle into the
intervertebral foramen to perform an injection at the nerve root area
this is a
transforaminal (through the foramen) epidural injection.
With
this type of epidural, the physician injects the medication
into the lateral epidural space “bathing” a specific spinal nerve as it
exits
the spinal cord. For this approach, you’d use a different set of codes,
as
follows:
•
64479 -- Injection, anesthetic agent and/or steroid,
transforaminal epidural; cervical or thoracic, single level
•
+64480 -- … cervical or thoracic, each additional level (list
separately in addition to code for primary procedure)
•
64483 -- … lumbar or sacral, single level
•
+64484 -- … lumbar or sacral, each additional level (list
separately in addition to code for primary procedure).
Add-on
rules:
You should report 64479
and 64483 as the primary codes for the first transforaminal injection
to the
cervical/thoracic or lumbar/sacral levels, respectively. Use add-on
codes 64480
and 64484 for each additional injection at the cervical/thoracic or
lumbar/sacral levels, respectively.
Example:
The physician administers
transforaminal ESIs at the right L4-L5 and L5-S1 intervertebral spaces,
two
different levels. You should report 64483 for the first lumbar
injection and
64484 for the additional level injection.
Find
Out if You Qualify for Fluoro Code
Increasingly,
physicians are using imaging guidance to verify
precise needle placement for the ESI. You may report fluoroscopic
guidance
separately with 77003 (Fluoroscopic guidance and localization of
needle or
catheter tip for spine or paraspinous diagnostic or therapeutic
injection
procedures [epidural, transforaminal epidural, subarachnoid,
paravertebral
facet joint, paravertebral facet joint nerve or sacroiliac joint],
including
neurolytic agent destruction).
The
2008 Medicare physician fee schedule lists an allowable reimbursement
range of approximately $50 to $86 for 77003 (global service), depending
on
where your office is geographically located.
Watch
for:
The physician needs to
include documentation that he used fluoroscopic guidance for the
procedure,
says Stacy Gregory, RCC, CPC, owner of Gregory Medical
Consulting
Services in Tacoma, Wash.
Don’t get confused: The parenthetical
note following 77003 states that
codes such as 62310-62319 include “injection of contrast during
fluoroscopic
guidance and localization.” This means that a provider cannot
separately bill
for the injection of contrast if performed during fluoroscopic
guidance,
but the note does not restrict a provider from reporting 77003 with
these
epidural injection codes.
Payer
Policy May Offer ICD-9 Answers
Matching
your ESI and fluoro codes to the proper ICD-9 code is
essential for proving medical necessity. Many payers, including most
Medicare
carriers and some commercial payers, have coverage policies that spell
out the
diagnoses that indicate ESI medical necessity.
Example:
Aetna states that
providers should administer therapeutic selective transforaminal
epidural
injections as part of a comprehensive pain management program.
Administration
of more than three such injections per six months is subject to medical
necessity review. They are generally medically necessary when used for
“identifying the etiology of pain in persons with symptoms suggestive
of
chronic radiculopathy, where the diagnosis remains uncertain after
standard
evaluation (neurologic examination, radiological and neurodiagnostic
studies)”
(http://www.aetna.com/cpb/medical/data/700_799/0722.html).
The
following list shows some of the conditions and corresponding
ICD-9 codes indicated to support medical necessity for epidural
injections by
many payer policies:
•
722.0-722.2 -- Displacement of intervertebral disc without
myelopathy…
•
722.4-722.6 -- Degeneration of intervertebral disc…
•
722.8X -- Postlaminectomy syndrome…
•
723.0, 724.0X -- Spinal stenosis…
•
723.4, 724.4 -- Neuritis or radiculitis…
Remember:
You must base your ICD-9
code on the documentation. You should never choose a code based solely
on what
the payer covers.
Break
Out the HCPCS Manual
In
addition to the procedure and diagnosis, you may report the
steroid used if your practice bears the cost for an ESI, such as when
you
perform it in the physician’s office.
Drugs
the physician may use in an office setting include the
following, says Eman Danial, CPC of Westgate Pain Management
Group in
Cleveland, Ohio:
•
Versed, J2250 (Injection, midazolam HCl, per 1 mg) for
moderate/conscious sedation
•
Depo-Medrol, J1020 (Injection, methylprednisolone acetate, 20
mg) or J1030 (Injection, methylprednisolone acetate, 40 mg)
•
Cortimed/Depo-Medrol, J1040 (Injection,
methylprednisolone acetate, 80 mg)
•
Marcaine (Bupivacaine) or Sodium Bicarbonate, J3490 (Unclassified
drugs) -- Medicare does not cover these, but other payers may.
If
you perform the procedure in an ASC or outpatient hospital
facility, the facility provides the medications ,and you should not
include
them in the physician’s billing, Danial adds.
Put
Your ESI Coding Skills to the Test
Now
that you’ve read about ESI CPT, ICD-9 and HCPCS coding, decide
how you would code the following ESI scenario, and then check your
answer
below.
Example:
In the office, your
physician administers an L3-4 interlaminar lumbar ESI for a patient
with a
herniated lumbar disc. He uses fluoroscopy to guide needle placement.
The drug
injected is 40 mg of Depo-Medrol.
Solution:
You should report the
single lumbar interlaminar injection with 62311 and the fluoroscopy
with 77003.
Report the Depo-Medrol with J1030. For the diagnosis, you should report
722.10
(Displacement of lumbar intervertebral disc without
myelopathy).
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