# Epidural steroid injection



## nasaga (Oct 26, 2010)

Hello,
I will appriciate any help with this case. 
Doctor did a ESI,   (#3? I dont know if this matter) and office visit .He put the following codes:

99212  -25
77003  -59
98925 -59
J2001
J1030
Q9965
62311
64493
This is so confusing   ...is it ok to use 62311 and 64493?
He is new to our practice so is coding.
Thank you for any help
I just dont know if this should be coded this way.. Thank you again


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## yulianikmiller@hotmail.com (Oct 26, 2010)

I can help you with correct coding if you give me following information 
Type of ESI, ie. single or transforaminal . If transforaminal – unilateral or bilateral
Level of a spine


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## dwaldman (Oct 26, 2010)

99212 -25
I would review the definition of the 25 modifier with the physician and verfiy that a "separate, identifiable visit" which went "above and beyond" the typical pre and post procedure interaction between the physician and patientwas performed. At the practice I work at we do not bill visits with epidurals or any other injections for follows up patients. Here is a link that might be helpful
http://www.wpsmedicare.com/part_b/education/modifier_25.pdf
77003 -59
According to the CPT book, Fluoroscopy is required and inclusive (not separately reportable) with 64493. In AMA's CPT Assistant article on Facet Injections from Sept 04, they state Spinal fluoro code 76005/77003 can be reported per spinal region. Since both the epidural and facet where in the same spinal region, You should not bill 77003. Also if you look at the NCCI policy manual, for coding based on these edits, 77003 is reported once per encounter regardless of spinal regions that are involved. In my opionion, most carriers follow the NCCI edits or a very similiar verison that they install in their software.

98925 -59
Not sure which this bundles with since you have 59 but I can not comment because I am not familiar with this procedure
J2001
The descriptor for this code states "intravenous infusion" This is not for reporting an "injection" of lidocaine. This is also considered bundled into 62311 for example. There is anothercode for non medicare carriers: S0020 bupivaine but you will this is typically bundled and the cash poster will spend time doing adjustments on this.
J1030
Patient received a injection of fentanyl? .1mg equals 100 micrograms which equals a 2ml vial. Here is a link for a drug calculator
http://www.palmettogba.com/palmetto/mc.nsf/ivr_display?openform
Q9965
Usually only reported for diagnostic procedures where closer to 10ml or more used.
62311 
64493
You are billing for drugs but I don't see Kenalog or depo medrol. Might want to show physician the LCD for Facets for Medicare. There might be a comment on performing mulitple types of injections during same encounter.


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## dwaldman (Oct 26, 2010)

Sorry you do have depo medrol forJ1030 40mg I don't why I thought it was J3010 for fentayl. The only thing is epidurals that I see are usually 40mg or 80mg. Would you be missing the drugs adminstered for the facet injection?


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## mitchellde (Oct 27, 2010)

My question is what does the documentation support?  This says there was a manipulation along with an epidural, along with a facet joint injection.  All in the same session?


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## nasaga (Oct 28, 2010)

Thank you all  for help

The note only states office visit and ESI #3, and all this medicine I posted before.
 If someone can tell me if doctor can perform two facet joint injection at one office visit or only one is allowed per visit?

Thank you


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## dwaldman (Oct 28, 2010)

The note only states office visit and ESI #3, and all this medicine I posted before.
If someone can tell me if doctor can perform two facet joint injection at one office visit or only one is allowed per visit?

Thank you 

If the you have a documented office visit and epidural. Then you need to review to see if the office visit is separately identifiable visit. Typically when the patient comes in for the third epidural steroid injection there is not a separate office visit. This is very important you get this right because billing a visit with a 25 modifier when the documentation does not support it can cause some major problems.  I would go over these charges with the physician who performed explain to him the situation with the visit and let him understand the concept so you are the same page. The procedure note of the ESI has to support the documentation of the j codes you provided. J2001 is bundled and most likely incorrect because this is for intravenous infusion of lidocaine. If the physician is attempting to provide the HCPCS codes to the drugs he needs to realize this. I would also question the 9 series for i think spinal manipulation. Why did he list this? You can report a two level facet block which you need to request the physician to document in the procedure note which facet joint were targeted in the procedure such as L3,L4,L5 medial branches were blocked which correspond with L4-L5 and L5-S1. Counting per facet level can be understood thru obtaining back issue of CPT Assistant Sep 04.


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## mitchellde (Oct 29, 2010)

If the note only states a vist and the 3rd ESI plus the meds... then I agree with the above, there cannot be an office visit billed as you do not meet the criteria for a separate office encounter when this is a planned return for a 3rd ESI.
If no manipulation is documented then this code is not billable
Also did he perform an Epidural or a facet injection?
From what you have given the only billable codes are
62311
J1030


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