# transforaminal epidural injection



## bench (Oct 12, 2012)

Hi,

MD performed transforaminal injection on:

LT L4-L5 then  
LT L5-S1 and RT L5-S1.  

How would you code this please.

Thanks.


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## Jamie Dezenzo (Oct 12, 2012)

64483 LT (L4L5)
64484 50 (L5S1)

Have a nice weekend!


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## bench (Oct 12, 2012)

Thank you so much for your reply.

I coded it the same since the lay description is by the level and clearly the op report says
LT L4-L5 ( first level) AND LT L5-S1 AND RT L5-S1 (second level). This is an old claim but there is this Medicare contracted audit agency stating that this is incorrect. Medicare do not accept modifier 50 so what I did was:

64483-LT
64484-LT
64484-RT

They said that the 64484-RT is incorrect as there must be a primary code first as this is an add on code. 

Your opinion please. Thanks.


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## Jamie Dezenzo (Oct 15, 2012)

Correct, depends on your Medicare carrier may want RT/LT rather 50.


Per my LCD:

The CPT codes 64479-64484 (transforaminal epidurals) have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, file with modifier –50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier –LT or –RT.

Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.


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## mitchellde (Oct 15, 2012)

I agree with Jamie, Medicare on a national level accepts the 50 modifier per the Medicare Manual.  I am not sure who in your area told you that Medicare does not, but that advice is inconsistent with the overall Medicare policy.


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## bench (Oct 15, 2012)

Thanks for you input guys. I really appreciate this. Here's the thing. We are an ASC and we are following the PALMETTO GBA JI B and here is what I see in their website:

•Indicator 1: The 150 percent adjustment for bilateral procedures applies. Report bilateral procedures with CPT modifier 50 and a quantity of '1', or report on two separate detail lines with HCPCS modifiers RT and LT. If the code is reported with CPT modifier 50 or is reported twice on a single date, payment will be based on the lower of the total actual charge for both sides or 150 percent of the fee schedule amount for a single code. Note that the bilateral pricing rules are applied before other 'multiple procedure' rules. 

It says here that I can use mod 50 or LT/RT. This is actually got paid by medicare before since this is an old claim. Now this audit agency is sending us notice of over payment with the remarks that I stated above. I also looked in our LCD PART B and there is non in my area. 

Thanks for looking through this.


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## Jamie Dezenzo (Oct 17, 2012)

Maybe an issue wanting to show billling 64483 50/or RT/LT (L5S1) and 64484-LT (L4L5)....Having the the prim procedure as bilateral rather than the add-on code.


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## bench (Oct 17, 2012)

Can you do that like backwards? 64483-50 (L5-S1  2nd level) and 64484-LT (L4-L5 1st level)? Or maybe I should have coded it the way you did:

64483-LT
64484-50

but technically aren't they the same with

64483-LT - 1ST LEVEL L4-L5
64484-LT - 2ND LEVEL L5-S1
64484-RT - 2ND LEVEL L5-S1

Well I guess I will just wait till I get the medicare final decision for this and I will just make an appeal.

Thanks so much.


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## Walker22 (Oct 18, 2012)

It's not backwards... "1st level" doesn't necessarily mean the one that is highest up on the spinal column. It means first level billed. You have 2 levels here... one is bilateral, and one is unilateral. You should always list your bilateral procedures first. In this case:

64483-50 (L5-S1 Bilat)
64484-LT (L4-L5 Unilat)


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## bench (Oct 18, 2012)

IC. Thanks so much. Is there any of you guys experienced this getting audited from an old claim and what did  you do? If medicare decides to pull back the over payment, do you think  I can still make a corrected claim as this is technically a modifier error but this claim was from year 2009. If I can do a possible appeal what do you think is the proper explanation for this. The only reason I can think about is if this error were captured during the time it was processed and got rejected then I can immidiately corrected this error. Any advise. Thanks very much.


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