# Multi approaches at one injection visit



## nan.coder (Dec 13, 2011)

We have a physician who insists that an ESI and a TF ESI can be performed at different levels on the same visit. Usually the ESI is below the TF ESI.  Can an ESI and TF ESI be billed on the same day at difference levels?  

NB


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## dwaldman (Dec 13, 2011)

Here is some information I have on this, below was from the AMA CPT Network, I don't believe it was published in CPT Assistant, For NCCI they have a mutually exclusive edit with the CPT with the higher RVU being the column two code that would bundle. You could write NCCI and try to get more clarfication or the poise the question to the AMA.

Date: 06/22/2010 

Surgery 

Nervous System 

Question 

In which instances would it be appropriate to report codes 64483 and 62311 together? 

Answer 

Code 62311, 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; lumbar, sacral (caudal), describes epidural or subarachnoid injections of non-neurolytic substances including opioids, steroids, antispasmodic, and anesthetic substances, and does not differentiate between types of substances injected, but rather focuses on the route of administration (ie, single injection [not via indwelling catheter] versus continuous infusion or intermittent bolus via catheter). However, it is important to recognize that code 62311 excludes injection/infusion of a neurolytic substance, which is reported by codes 62280-62282. Therefore, based on the above information and in answer to your specific question, since code 62311 includes the injection of non-neurolytic substances, it would not be appropriate to separately report code 64483, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level. 

______________________________________________________________________
Below is from a Medtronics 2009 webinar presented by Joanne Mehmert: Pain Management Billing and Coding

__________________________________________________ _______________
Transforaminal/interlaminar

Q I have a provider who did a right sided L4-L5 transforaminal epidural steroid injection and interlaminar epidural injection at L4,L5,S1 How would I code for this

A When two different surgical approaches are used to accomplish the same goal, it is not appropriate to report both procedures. In the situation described, the injections are made at the same spinal level, a contiguous anatomical region; it would not be appropriate to report both procedures. A transforaminal epidural 64479/64483 is mutually exclusive to a translaminar epidural 62310/623111.

The CCI shows that a transforaminal epidural 64479/64483 is mutally exclusive to a translaminar epidural 62310/62311. Although a bypass modifier (59) is allowed, the modifier is not appropriate when the injection is at the same spinal level to treat the same condition. 

If the provider attempts to perform the injection using the interlaminar technique and finds that the dye does not spread, then changes his/ approach to the transforaminal, only the transforaminal injection should be reported. AMA literature show examples of this coding principle for endoscopic procedures converted to open procedures---report only the "open" code.


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## brockorama01 (Dec 14, 2011)

Quick comment regarding 62311's and 64483's together.

Routinely doing both at the same time is a recipe for denial.  If your physician wants his billing staff to have to appeal every claim here are few suggeestions:

1.  Make sure there are separate dx's!  64483's address primarily radicular back and leg pain and 62311's address primarily localized pain.  

2.  Make sure the blocks are at different levels...the further apart the better (i.e. L5 vs L2/L3)

3.  Dictate VERY clearly the rationale for doing both blocks.

4.  Remind the physician that reason for the exclusion is that most pt's with radicular pain also have axial/localized back pain and vice versa.  Medicare is highly skepitcal that two are needed at the same time.  If one type of block is not successful, bring the pt back and do the other.

5.  Finally, over the years,  will a lot a time and effort and appeals... I can get 3 out of 10 paid by Medicare and 6 out of 10 by commercial carriers.  Is it worth it?

Brock Berta, CPC-A, MBA
Billing Czar


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## nan.coder (Dec 15, 2011)

Thank you both.  I've printed out this info to show the physician.  NB


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