# CMS on Epidural Injections w/ Fluoro



## Tracey Thompson (Jan 24, 2012)

A client has supposedly received a letter from CMS stating that CMS will no longer pay for epidurals done without the use of fluoroscopic guidance.  I am concerned of whether or not this is true.  If anyone can give advice as to whether or not CMS does/will require the use of fluoroscopic guidance in order to bill for an epidural injection, please let me know ASAP.

I do know that there are instances such as RFA, where if fluoro is not used that the procedure is actually coded as a completely different procedure.  Could this be the case with this as well?

Any help is greatly appreciated!!!


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## donnajrichmond (Jan 24, 2012)

From CMS or from their local Medicare contractor?  Epidural (62310-62319) or transforaminal epidural (64479-64484). 
Transforaminal epidural require and include fluoro or CT guidance or those codes cannot be coded.  But I haven't seen anything cnocerning 62310-62319.  If you get a copy of the letter I'd love to see it!


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## Tracey Thompson (Jan 25, 2012)

*Thanks!*

Thank you so much for your quick response.  I have not actually seen a copy of the letter, nor do I know whether it was from MCR or the local.  This question has actually been filtered down to me from upper management.  

The issue at hand are epidural injections (62310-62319).  Because the provider thinks he will not get paid unless also performing fluoro (which he is unwilling to do), he is going to start refusing to see MCR patients for this service.  Personally, I am concerned that this is more of a ploy on someone's part to weed out the Medicare patients and to spend more time seeing commercial patient (ie, more money for the same procedures).

I did look up the LCDs for this procedure, and they do state that fluoro is required to be performed in order to meet MCRs standard of care.

My next question is, if he performs and epidural steriod injection but without fluro.... Is there a way that we can bill 20600 for injection into a small joint?  My first instinct was no, because I feel like we are just coding something to get it paid.  But then my thinking changed to the injection is not consider and ESI by medicare without the use of fluoro, so shouldn't we be able to code is as something other than an ESI????

Sorry for rambling, the more I look at this the more confused I get.  Any insight would be greatly appreciated!!!


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## donnajrichmond (Jan 25, 2012)

Some contractors are requiring fluoro, but CMS does not as yet.  Here is what the LCD from First Coast (Florida) says:  "Epidural injections, regardless of the approach used, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary."
In my opinion, changing 62310 or 62311 to 206xx would be dangerous.  While the instructions for transforaminal do say to do that, the guidelines for 62310-62311 do not.  
What I think he absolutely needs to do is to contact his specialty society.  Let them know what the local contractor is doing.  The societies are very good about interceding when necessary.  (and if they tell him to change to 20600 plus fluoro, then he's got an official go-ahead to do that.)


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## Tracey Thompson (Jan 25, 2012)

Yes, it may very well be a local contractor determination versus a ruling by Medicare.  The part of the LCD that I was referring to stated "Fluoroscopic guidance must be utilized in the performance of single nerve root/transforaminal injections to ensure the precise placement of the needle and medications injected."

While I understand that using code 20660 versus 62310-62319 is dangerous, in this situation I feel that it is warranted.  According to the LCD fluoroscopic guidance is required in order for the procedure to be considered an ESI.  So if fluoroscopic guidance is NOT used, wouldn't that just make the procedure a joint injection??

Again, all input is greatly appreciated!  This is where coding/billing get a little grey instead of black and white!


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