# Transforminal Lumbar Injections - My doctor is wanting



## nicolechaller@gmail.com

My doctor is wanting to bill insurance for the following....

64483
64484
36000
94770
94761
72275
96365
J2250
J3010
J3301
J1094

I'm relatively new to pain management billing and would like confimation on this. This procedure was performed in office and I'm POSITIVE he's unbundling (36000 included w/ 96365) things but unless I can show him documentation, he wants all codes included.  I myself had this procedure done by another physician and don't recall this many codes when I was sent am itemized statement. Please help!


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## dwaldman

As seen below the following codes would be bundled into 64483 and it would not be appropriate to place the modifier 59 since they are integral to the performance of the procedure and performed during the same encounter. If an epidurogram is performed it would require a formal contrast study to be documented and the purpose of this was for diagnostic and assist with further diagnosis of the patient. With other imaging techniques available such as MRI or myelogram, you would want to be fully sure the intent was diagnostic and documentation supports that. The additional information below regarding why these codes are bundled is from the CMS National Correct Coding Inititiave policy manual. I would review these statements with the physician so he is more familiar with NCCI and what is considered incidental per Medicare standards.


Code 72275 is a component of Column 1 code 64483 but a modifier is allowed in order to differentiate between the services provided. 

Code 96365 is a component of Column 1 code 64483 but a modifier is allowed in order to differentiate between the services provided. 

Code 36000 is a component of Column 1 code 64483 but a modifier is allowed in order to differentiate between the services provided. 

Code 36000 is a component of Column 1 code 96365 but a modifier is allowed in order to differentiate between the services provided

Code 94770 is a component of Column 1 code 64483 but a modifier is allowed in order to differentiate between the services provided. 

Intravenous access (e.g., CPT codes 36000, 36400, 36410) is not separately reportable when performed with many types of procedures (e.g., surgical procedures, anesthesia procedures, radiological procedures requiring intravenous contrast, nuclear medicine procedures requiring intravenous radiopharmaceutical).

The global surgical package includes the administration of fluids and drugs during the operative procedure. CPT codes 96360-96376 should not be reported separately. Under OPPS, the administration of fluids and drugs during or for an operative procedure are included services and are not separately reportable (e.g., CPT codes 96360-96376).

2. Medicare Anesthesia Rules prevent separate payment for anesthesia services by the same physician performing a surgical or medical procedure. The physician performing a surgical or medical procedure should not report CPT codes 96360-96376 for the administration of anesthetic agents during the procedure. If it is medically reasonable and necessary that a separate provider (anesthesia practitioner) perform anesthesia services (e.g., monitored anesthesia care) for a surgical or medical procedure, a separate anesthesia service may be reported by the second provider.

3. Many procedures require cardiopulmonary monitoring either by the physician performing the procedure or an anesthesia practitioner. Since these services are integral to the procedure, they are not separately reportable. Examples of these services include cardiac monitoring, pulse oximetry, and ventilation management (e.g., 93000-93010, 93040-93042, 94760, 94761, 94770).


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## CoderinJax

*72275 with 76000*

I also have a question in regards to CPT 72275-59 (Epidurography) billed with CPT codes 64483, 76000-59, 77002, J0702, and 94760. 

I'm looking at a record where our Physician is billing the above codes and I've hit a wall in understanding 2 pieces of the codes/records. Below are my 2 questions.

I get that 77002 is not the correct CPT code for Fluoro (which is inclusive of 64483) and that 77003 should have been billed even though it will deny as inclusive.
But the Doc is also billing 76000 (Stand alone fluoro) and 72275. 77003 is bundled into 72275, but he's billing 76000-59 which is odd and it's bypassing the carriers edits. (Why would he bill this?? ) So that's issue #1, and if anyone can explain why he'd be doing this and if it's possibly ok, I'd appreciate it.  If it's not ok, why? (Any AMA driven material would be awesome!)

Question/issue #2: In his Epidurography report, it ONLY states the following: 
*"1 cc of 240 lohexol and 1 cc of air was injected and seen to spread in a typical epidural fashion fluoroscopically. The flow of the lohexol was seen on the Epidurography. This graph was used to confirm proper placement."*That's it. Is that enough to warrant an Epi? Doesn't it sound like it really was mainly for the needle placement of the injection? (64483) No mention of the images being documented/stored, so I'm leery of this. Anyone have any solid advice as to whether they'd allow this or give feedback to the Physician that he's not documenting enough?

THANK YOU so very much for anything you guys could help with!


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## marvelh

ABSOLUTELY do not bill 76000-59 for the fluoroscopy used as image guidance for injections.  Practices have been audited for that type of billing and had to pay back large sums of $.  The code descriptor for 76000 states "separate procedure" and the use of modifier 59 is telling the payer that you have performed separate fluoroscopy outside / separate from the fluoro used in the injection procedure.  Some practices erroneously think that they use the 76000 code to be paid for owning the fluoroscopy machine but that is NOT accurate.  The payment for the "fluoroscopy machine" use is included the technical component of the image guidance.  

It is also  not compliant to separately bill for 77003 if the fluoroscopy is included in the procedure, i.e. 64483, where you are expecting the payer to catch the incorrect billing and deny it.  This type of billing is again setting the practice up to potential payer audits and refunds if they incorrectly pay for the fluoro.

The documentation does not support that a separate diagnostic epidurogram was performed.  Just because providers inject contrast does not mean that a diagnostic test was performed; rather the contrast is used to verify needle placement, i.e. that the needle is not in the incorrect place.


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## CoderinJax

THANK YOU, thank you so very much! This helps with what I was thinking, only I needed to hear it from someone else. Sounds like I'll be giving feedback on both the Fluoro as well as the Epidurography, both not being billable/payable.


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