# L5/S1 ESI & Bilat SI joint injections



## nan.coder (Dec 20, 2011)

Bilateral SI joint arthritis and lumbar radiculopathy were given as diagnosis.  ASCExpert shows that 27096 and 62311 may not be billed together but a modifier is allowed.  Doc says its OK because WC is paying.  

What is the guideline for ALL insurance carriers - can these procedures be billed together at the same session?


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## dwaldman (Dec 21, 2011)

The injections are at two separate sites, I would bill as such 

62311-59
27096
77003-26

or 
62311-59
27096
77003-26 59 in 2012

The CCI edit falls under Standards of medical / surgical practice according to Supercoder, but when you look at the NCCI policy manual at the chapter 1 general coding principles and read "coding based on standards of medical/surgical practice" the two procedures do not represent integral services and I believe the 59 modifier is warranted. Regardless of the carrier, these are separate distinct procedures and I believe they can be separately reported, if reported similiar with the modifiers it could prevent denials if a non-Medicare carrier follows NCCI or their verison of NCCI has similiar edits.


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,
Revision Date (Medicare): 1/1/2012
I-10
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)
- Application of 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:
Revision Date (Medicare): 1/1/2012
I-11
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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## LeslieJ (Dec 22, 2011)

Just wanted to confirm a comment that was made in the original post:

"Doc says its OK because WC is paying."

This is sorta-kinda true.  Although we should adhere to our usual coding/billing rules, WC is its own bird in terms of how/what to code.  Depending on your state, if these codes were approved, these are the the only codes you can submit, even if other procedures may have been done.  

Ditto the ICD-9 - if the approved Dx is one thing, even if other things are found incidentally, you need to make sure that the approved Dx is the primary code.  

Having said that, we do need to recognize the basic rules of coding in that 27096 and 62311 are, in fact, bundled.  Just because we _can_ unbundle per CCI Edits, doesn't always mean that we _should_.  From what you wrote, sounds like you already know that.  There are plenty of cases out there where WC has been challenged by a physician with the mentality that just because it's WC, we can bill whatever way we want, and the physician has lost.

David Waldman has given some good information above regarding the coding...wishing you good luck!

L J


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