# Injections denied by Tricare



## dyoungberg (Feb 15, 2013)

I billed the following 2 procedures to Tricare with 62311, 77003 & 64483 with diagnosis codes 721.3,724.2, & v58.61.  Tricare has denied 62311 & 77003  as "The procedure of 62311 is mutually exclusive to a procedure done on the same date of service.  The clinically more intense procedure is recommended for reimbursement.

DIAGNOSIS:   LUMBAR RADICULOPATHY,  INTRACTABLE LOW BACK PAIN 

PROCEDURE:  
1. LUMBAR EPIDURAL STEROID INJECTION AT L4-5 
2. FLUOROSCOPY  

SUMMARY: The patient has history of persistent and severe low back pain with radicular symptoms. The patient has been tried on a variety of conservative measures with only limited response. It was decided to proceed with lumbar epidural steroid injection. The procedure was thoroughly explained to the patient and informed consent was obtained.  The patient stated she had discontinued her Coumadin prior to the procedure. 

The patient was brought to the procedure room and placed in the lateral position. The field was prepped with Betadine and draped in the usual manner. Local anesthesia with 1 cc 1% Lidocaine was injected at the L4-5 level. Under fluoroscopic guidance, a 20G epidural Tuohy needle was introduced into the L4-5 interspace utilizing the loss of resistance technique. A mixture of 0.25% Marcaine, Decadron and Toradol was injected without difficulty. The needle was removed and Tegaderm was placed. The patient tolerated the procedure well and will be observed in the recovery room for one hour prior to being released. The patient will be reevaluated in the office in one week or earlier, if needed.  

**********************************

DIAGNOSIS:   LUMBAR RADICULOPATHY, INTRACTABLE LOW BACK PAIN 

PROCEDURE:   FLUOROSCOPICALLY-GUIDED TRANSFORAMINAL LUMBAR EPIDURAL STEROID INJECTION AT L5  ON THE LEFT SIDE 

INTRODUCTION:  This patient has history of persistent and severe low back pain with radicular symptoms, worse on the left side. The patient has been treated with a variety of measures with only limited response. It was felt the patient would benefit from transforaminal lumbar epidural steroid injection. The procedure was thoroughly explained to the patient and informed consent was obtained.  
The patient stated she had discontinued her Coumadin prior to the procedure. 

DESCRIPTION:  The patient was taken to the OR and placed in the prone position. The skin and subcutaneous tissues were anesthetized with 1% Lidocaine, after sterilizing the field in the usual manner with Betadine. Under fluoroscopic guidance, a 22G Tuohy needle was introduced through the upper edge of the neural foramen of L5 on the left side. On withdrawal, care was taken to check for CSF or blood and none was noted. The loss of resistance technique was used. Once the space was identified, 2 cc Decadron was injected without difficulty. The needle was removed and a band-aid placed. 

During the procedure, there was constant oral communication with the patient. There was no change in the neurological status during the procedure. The patient tolerated the procedure well. The patient is to apply heat and ice, alternating, to the back. The patient remained at the surgery center for 20 minutes following the procedure and at the time of discharge indicated their pain had decreased and their ROM had increased. 


I can't find anywhere on the Tricare website or in their handbook stating their injection guidelines.  Should I appeal this again and if so, using what reasoning?  I'm lost on this one.  The patient is on anti coagulants, but they still denied payment of all charges.

Thanks!

Debbie
Billing Representative
NW FL Surgery Center


----------



## dwaldman (Feb 15, 2013)

Was 62311 and 64483 performed on separate days?


----------



## dyoungberg (Feb 22, 2013)

No, performed on the same day.


----------



## dwaldman (Feb 23, 2013)

It would be based on payer interpretation, if they cover a interlaminar injection at L4-L5 and transforaminal injection at L5-S1. Per NCCI the code pair is mutually exclusive with the column 2 code as 64483 with modifier allowed. Might want to review with the physician that this code pair typically has gray area on coverage together. Additionally could write NCCI for them to provided greater realization of when modifier 59 would be allowed with CPT 64483 when billed with 62311.


----------

