# Pain mgmt injections with flouro guidance - anesthesiologist and radiologist



## MnTwins29 (May 13, 2011)

Hi - I am looking for guidance.  One anesthesiologist does PM procedures in our radiology dept and these are injections in which the guidance is included in the code, such as 64490.  Our radiologist will dictate a reading for the images taken by the tech and the anesthesiologist will also dictate a procedure report.  Can both physicians bill for the same code, 64490-26?  I have also been told that the radiologist should bill 77003, but I am not comfortable with that as I believe that would be improper unbundling.  Is there a proper way to bill these so both doctors get paid?   Thank you.


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## dwaldman (May 15, 2011)

In January, one of the ladies I work with also works in a radiology department during the night time. She told me in January that there was Memo sent out to the employees explaining that when the doctors performs a fluoroscopically-assisted placement of a percutaneous electrode/63650, that they were no longer to put the charge master number in for any radiolgoical service (eg 77003, 77002, 76000).

I let her know that this was because the coding department at that hospital had seen CPT Assistant and knew that fluoroscopic guidance was part of performing the procedure and not separately reportable. That although the radiologist will dictate a small report stating fluoroscopic image of needle place by PM physician and the anatomically location, that with the change in coding guidlines that they had to follow these guidelines and no longer can they just key in the charge master number because too many would have to be corrected before the claims went out.

It is the same in your case, 64490 includes image guidance. There is not a professional and technical portion for radiology to report for this procedure. It is not well Medicare won't pay for but there are still some carriers that do. It is required and included in the code. They will have to understand this one procedure they will not be able to report on their side.


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## MnTwins29 (May 16, 2011)

*Thank you*

Thank you, dwaldman.  If I am reading your response correctly, this applies to any professional service, correct - that it can only be reported by one physician?  So, to carry my example of 64490 one step further, if the anesthesiologist reports the professional portion of the procedure, the radiolgist cannot bill for this procedure at all correct?  And if so, what should the radiologist or his/her organization do so that these services can be compensated?


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## dwaldman (May 17, 2011)

One of the physician I am working for with, goes to the outlying facilities and over the fax I see reports that describe the anatomical location he is placing the needle and that is it. Not describing performing the injection but just verfication that fluoroscopy was used and that the needle was seen at a certain anatomical region. This is provided by the hospital or a radiology group within the hospital. Which i am not aware of the arrangement between the hospital and this radiology group.

The physician that is performing the pain management procedure will describe for example a fluorsocopic guided SI joint block or epidural as a procedure note . We will bill 27096 77003-26 modifier or 6231X 77003-26 modifier. 

We don't ever get calls stating, Oh the radiologist at the hosptial provided that fluorosocpic report and he billed 77003-26 so you can't.

 It doesn't seem to work this way. Because the radiologist is not performing the procedure, it is really the physician performing these types of procedures that are interpreting the fluoroscopic screen image to be able to accurately perform the injection

So if you look at 64490 which requires and includes 77003. To safely and accurately perform the procedure, the physician who performing the injection has utilize the fluoroscopic films to make sure the target medial branch or placement within the facet joint is placed to utmost degree of certainty.

If the hospital or the radiology group needs to have a document that fluoroscopy was used and anatomcial location of that needle to place in the chart that is one thing, but regardless if it is a procedure that 77003 is separately reportable or not. The professional portion of this service (fluroscopy for injection procedures) is not reported by the radiologist, if the radiologist is not performing the actual procedure.

It is perform by the physician performing the procedure and this reported by the performing physican.


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## KimberlyLanier (May 20, 2011)

Could you please tell me if 27096 and 64483 are now bundled proceudures?  Per CCI it shows a 1 which means it is allowed.  Is there anything that you know of that states they can't be coded together?

Thanks Kimberly CPC


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## dwaldman (May 20, 2011)

Ingenix's book--- Medicare Correct Coding Guide, provides the NCCI edits with icons which they provide which edits found in chapter one of NCCI policy manual in which was reasoning behind the edit. They also provide this in certain verisons of Encoder.

As you stated, 64483 a column two code of column one code 27096, According to Ingenix Encoder I am using it states this is for edit: "Standards of medical/surgical pratice"
Below I copy and pasted this edit. This edit description describes services that are "integral" to another procedure. Maybe they are referring doing SI Joint blocks and in a similiar anatomical region doing Sacral Selective nerve root blocks. The common response when dealing with the spine and NCCI, the response will be if done at separate levels then 59 could be considered. Although I have not written those who establish the NCCI edits or email my local Medicare carrier on this particular code pair. It would seem you have a couple of options. 

1. Use the email function on the Medicare carrier site you are billing them and ask them for clarification. 

2. Write NCCI creators see if they can clarify this 
National Correct Coding Initiative
Correct Coding Solutions LLC
P.O. Box 907
Carmel, IN 46082-0907

Attention:  Niles R. Rosen, M.D., Medical Director and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist

Fax #:  317-571-1745

3. Suggest to the physician that SI Joint blocks have bundling issues with many procedures and should be done as stand alone procedures as long it is in the best interest of the patient.

4. Since a lumbar transforminal epidural does not seem like an "integral" to an SI Joint block, apply the 59 modifier on 64483. There has been times in the past where edits were established the involved pain management procedures and were overturned after additional review and letters written. 

5. Then you have determine if you are going to try to bill 27096 64483-59 77003-26 59---Separate spinal regions, only report 77003 once per session---Meeting criteria of both AMA and CMS

B. Coding Based on Standards of Medical/Surgical Practice


Most HCPCS/CPT code defined procedures include services that are integral to them. Some of these integral services have specific CPT codes for reporting the service when not performed as an integral part of another procedure. (For example, CPT code 36000 introduction of needle or intracatheter into a vein) is integral to all nuclear medicine procedures requiring injection of a radiopharmaceutical into a vein. CPT code 36000 is not separately reportable with these types of nuclear medicine procedures. However, CPT code 36000 may be reported alone if the only service provided is the introduction of a needle into a vein.) Other integral services do not have specific CPT codes. (For example, wound irrigation is integral to the treatment of all wounds and does not have a HCPCS/CPT code.) Services integral to HCPCS/CPT code defined procedures are included in those procedures based on the standards of medical/surgical practice.

It is inappropriate to separately report services that are integral to another procedure with that procedure.


Many NCCI edits are based on the standards of medical/surgical practice. Services that are integral to another service are component parts of the more comprehensive service. When integral component services have their own HCPCS/CPT codes, NCCI edits place the comprehensive service in column one and the component

service in column two. Since a component service integral to a comprehensive service is not separately reportable, the column two code is not separately reportable with the column one code. 


Some services are integral to large numbers of procedures. Other services are integral to a more limited number of procedures. Examples of services integral to a large number of procedures include:


- Cleansing, shaving and prepping of skin

- Draping and positioning of patient

- Insertion of intravenous access for medication administration

- Insertion of urinary catheter

- Sedative administration by the physician performing a procedure (see Chapter II, Anesthesia Services)
- Local, topical or regional anesthesia administered by the physician performing the procedure

- Surgical approach including identification of anatomical landmarks, incision, evaluation of the surgical field,debridement of traumatized tissue, lysis of adhesions,and isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring

- Surgical cultures

- Wound irrigation

- Insertion and removal of drains, suction devices, and pumps into same site

- Surgical closure and dressings

- Application, management, and removal of postoperative dressings and analgesic devices (peri-incisional

- TENS unit

- Institution of Patient Controlled Anesthesia

- Preoperative, intraoperative and postoperative documentation, including photographs, drawings, dictation, or transcription as necessary to document the services provided

- Surgical supplies, except for specific situations where CMS policy permits separate payment


Although other chapters in this Manual further address issues related to the standards of medical/surgical practice for the procedures covered by that chapter, it is not possible because of space limitations to discuss all NCCI edits based on the principle of the standards of medical/surgical practice.

However, there are several general principles that can be applied to the edits as follows:


1. The component service is an accepted standard of care when performing the comprehensive service.


2. The component service is usually necessary to complete the comprehensive service.


3. The component service is not a separately distinguishable procedure when performed with the comprehensive service.


Specific examples of services that are not separately reportable because they are components of more comprehensive services follow:


Medical:


1. Since interpretation of cardiac rhythm is an integral component of the interpretation of an electrocardiogram, a rhythm strip is not separately reportable.


2. Since determination of ankle/brachial indices requires both upper and lower extremity doppler studies, an upper extremity doppler study is not separately reportable. 


3. Since a cardiac stress test includes multiple electrocardiograms, an electrocardiogram is not separately reportable.


Surgical:


1. Since a myringotomy requires access to the tympanic membrane through the external auditory canal, removal of impacted cerumen from the external auditory canal is not separately reportable.


2. A “scout” bronchoscopy to assess the surgical field, anatomic landmarks, extent of disease, etc., is not separately reportable with an open pulmonary procedure such as a pulmonary lobectomy. By contrast, an initial diagnostic bronchoscopy is separately reportable. If the diagnostic bronchoscopy is performed at the same patient encounter as the open pulmonary procedure and does not duplicate an earlier diagnostic bronchoscopy by the same or another physician, the diagnostic bronchoscopy may be reported with modifier 58 to indicate a staged procedure. A cursory examination of the upper airway during a bronchoscopy with the bronchoscope should not be reported separately as a laryngoscopy. However, separate endoscopies of anatomically distinct areas with different endoscopes may be reported separately (e.g., thoracoscopy and mediastinoscopy).


3. Since a colectomy requires exposure of the colon, the laparotomy and adhesiolysis to expose the colon are not separately reportable.


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## mlwilson (Jul 20, 2011)

I have a question regarding fluoroscopic guidence.  Is our physician who performs the fluoroscopic guidence required to have any special licensing or is this in their scope of practice?


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