# Cervical Epidural



## coderguy1939 (Feb 9, 2009)

Our outside coding agency is the following report with 62310.   We think it should be coded as 62318.  I'd like some feedback, please:


The patient was placed in the prone position with a pillow underneath the chest and the forehead resting on a headrest.  THe neck and upper thorax were prepped and draped in sterile fashion.  The flouroscope was placed in the posterior/anterior projection.  Lidocaine 1% was used for infiltration through a 27-guage 1-1/2 needle.  Using loss of resistance technique, a 17-guage Tuohy cannula was used to enter the cervical epidural space at the C7-T1 level.  There were no parethesias reported, nor was there aspiration of CSF or blood.  An Arrow radio-opaque Thera-Cath was advanced to the C3 region using flouroscopic guidance.  No parethesia was elicited.  After negative aspiration for CSF or blood, a continuous infusion of Isovue-M-200 water-soluble dye was used to indentify the bilateral C3-C7 nerve roots and lateral epidural space.  The patient received a continuous infusion of 2cc of 1% Lidocaine with 80 mg tramcinolone through the catheter.  The catheter and cannula were removed intact.  The patient tolerated the procedure well and was brought to the recovery room in stable condition.

Thanks for you input.


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## magnolia1 (Feb 9, 2009)

I am coming up with 62318 (because of the "infusion").


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## aschaeve (Feb 9, 2009)

The documentation states that the catheter was removed intact.  I would bill 62310, because it was not left in continuous (for days to come).

Alicia, CPC


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## Anna Weaver (Feb 9, 2009)

*cervical epidural*

I would use the 62310 see the following 2 CPT assistant Both from 2000. 

CPT assistant Jan 2000:
CPT Codes 62318 and 62319

CPT codes 62318 and 62319 describe a continuous infusion or intermittent bolus, including catheter placement of diagnostic or therapeutic nonneurolytic substance(s).  CPT codes 62318 and 62319 include the setup and start of the infusion, therefore, these services are not separately reportable.  For daily maintenance of the epidural or subarachnoid catheter drug administration, it is appropriate to report code 01996, Daily management of epidural or subarachnoid drug administration, separately.

Clinical Vignettes

A 45-year-old male has severe pain (rated at 8 on a scale of 0-10, where 10 is the worst pain) involving both legs and the lower back after multiple back operations over a 10 year period.  Various systemic medications (oral narcotic and nonnarcotic) and physical therapy have all failed to provide long-term pain relief.  It is felt that no further operations are likely to provide pain relief.

62318 and 62319

This patient is a good candidate for an epidural narcotic infusion or series of intermittent bolus injections.  A continuous infusion of narcotic and local anesthetic can be used for several days during aggressive physical therapy to try and break a cycle of sympathetic dysfunction (eg, from reflex sympathetic dysfunction or complex regional pain syndrome).  The catheter can also be used for a series of single injections over several hours or 1-2 days to test for narcotic pain relief versus pain relief from saline injections.  For 62319, the patient receives a subarachnoid narcotic infusion or a series of intermittent bolus injections in the lumbar, sacral region.

Description of Procedure

A catheter is threaded through the needle and placed in the subarachnoid space.  Through this catheter, a continuous infusion is started for several hours or several days.  Occasionally, as part of a detailed diagnostic or treatment regimen, multiple (3 or more) injections might be given through this catheter over a period of hours or 1-2 days.  These multiple injections often involve different substances, such as placebo injection or varying amounts of narcotic.

A catheter is threaded through the needle and placed in the epidural space.  Through this catheter, a continuous infusion is started for several hours or days.  Occasionally, as part of a detailed diagnostic or treatment regimen, multiple (3 or more) injections might be given through this catheter over a period of hours or 1-2 days.  These multiple injections often involve different substances, such as placebo injection or varying amounts of narcotic.

ALSO:

Injection, Drainage, or Aspiration Guidelines

In CPT 2000, the guidelines were revised to state: "Injection of contrast during fluoroscopic guidance and localization is an inclusive component of codes 62270-62273, 62280-62282, 62310-62319.  Fluoroscopic guidance and localization is reported by code 76005, unless a formal contrast study (myelography, epidurography, or arthrography) is performed, in which case the use of fluoroscopy is included in the supervision and interpretation codes.

Note from 3M:
 As of January 1, 2007, 76005 has been deleted. To report, use new code 77003. 


For radiologic supervision and interpretation of epidurography, use 72275.  Code 72275 is only to be used when an epidurogram is performed, recorded, and a formal radiologic report is issued.

For codes 62318 and 62319, use code 01996 for subsequent daily management of epidural or subarachnoid catheter drug administration."

Ÿ62310   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; cervical or thoracic

Ÿ62311        lumbar, sacral (caudal)

Ÿ62318   Injection, including catheter placement, continuous infusion or intermittent bolus, 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; cervical or thoracic

Ÿ62319        lumbar, sacral (caudal)

These new codes represent a reordering of the 1999 codes.  As part of a larger more logical scheme for spinal injections, all of the existing subarachnoid injection codes and epidural narcotic injection codes were grouped together.

These new codes do not differentiate between types of substances injected (eg, narcotic, anesthetic, steroid, antispasmodic), but rather focus 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 these new codes exclude injection/infusion of a neurolytic substance, which is reported by codes 62280-62282.


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## magnolia1 (Feb 9, 2009)

In the Coders Desk Reference, description of CPT 62310 does not include "catheter placement", nor does it mention "continuous infusion" as is noted in the Procedure Note in question.
CPT 62318 reflects both of those terms.


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## Anna Weaver (Feb 9, 2009)

*cervical epidural*

I guess I was looking at the time frame. CPT assistant states that 62318 is for intermittent or continuous, but it also says over several hours or days. I guess what we would need then would be the time frame for the procedure. That's what made me think it should be 62310 as this is for a single injection not through indwelling catheter. Since they removed the catheter after, I didn't consider this an indwelling.
Anyone else?


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## jdrueppel (Feb 9, 2009)

Due to catheter placement and continuous infusion I would bill this as a 62318.  

Julie, CPC


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## med-biller (Feb 15, 2009)

My vote is 62310.  Total time of infusion would need to be documented for the 62318 to apply.


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## kknapp (Feb 16, 2009)

*on Q Ice*

This is a "62319" procedure that one of our surgeons is wanting start doing. Upon research, per BCBS Anthem, 62319 is only considered medical necessary when both of the foolowing criteria are met
1.  The services are provided by an individual other than the attending physician performing the procedure; and
2.  Alternative types of anesthesia, sedation, or analgesia are not appropriate.

To me this means that the surgeon mentions above who is an pain managment anestesiolgist can not do the procedure as a treatment for pain.  

Is anyone else that is billing for this procedure as a stand alone procedure being paid?


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## jdrueppel (Feb 16, 2009)

kknapp,

I believe Anthem BCBS is referring to the regulation when the surgeon places the continuous catheter for postoperative pain management. Below is from the NCCI Policy Manual for Medicare Services.

"Medicare Global Surgery Rules prevent separate payment for postoperative pain management when provided by the physician performing an operative procedure. HCPCS/CPT codes 36000, 36410, 37202, 62318-62319, 64415-64417, 64450, 64470, 64475, and 90760-90775 describe some services that may be utilized for postoperative pain management. The services described by these codes may be reported by the physician performing the operative procedure only if provided for purposes unrelated to the postoperative pain management, the operative procedure, or anesthesia for the procedure."

Blocks for postoperative pain management are billable by the anesthesiologist when it is clearly documented that (1) block is for postoperative pain management  (2) per the request of the surgeon.

Julie, CPC


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## kknapp (Feb 16, 2009)

*on Q Ice*

Julie,

So what you are saying is an anesthesologist who is doing the 62319 for pain management (lower back pain) and not associated with post operative pain, should be covered.  Or do you feel that it would be considered not medically necessary.

Thank you for any help you can give me concerning this issue.  Our doc wants to move foward with this but I am not comfortable in stating that we would be paid.  Even the rep for the On Q ice gives us a letter for Medicare "ABNs" and commerical payors that state it may not be medically necessary.

Have you heard of anyone being paid for this procedure?


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## jdrueppel (Feb 16, 2009)

We do continuous epidurals for postop and post-trauma pain.  My services are inpatient.  Our Medicare carrier (WPS) has an LCD but we have no problems meeting the medical necessity diagnoses. Check to see if your carrier has an LCD.  In addition, I have not had any payment issues with any other payers. 

Julie, CPC


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## kknapp (Feb 16, 2009)

*On Q Ice*

Julie,

I agree, we have not had any problems with receiving payment for the procedure when it is done in addition with a surgical procedure for post operative pain, but this physician wants to do it as a stand alone procedure for back pain.  That is where I am having trouble.


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## jdrueppel (Feb 16, 2009)

kknapp,

Will these be inpatient services?  I have billed continous epidural services for as stand alone procedure (i.e. thoracic for rib fractures OR lumbar for pelvic fracture) for acute trauma. 

It might be easier if we could personally connect on this.  I sent you a private message.  

Julie


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## larkatin (Mar 17, 2009)

*62310 vs 62318*

I have been following this thread and today my physician came to me stating he wanted to start billing 62319 for lumbar and 62318 for cervical epidural steroid injections done thru a catheter. 

He stated that there are occasions (not every time) that instead of just using fluoro to find needle placement and do a single injection, he may thread a catheter and insert the medication thru it. Once the medication infiltrates, he removes catheter. I read 62318/62319 as catheter placement with continuous infusion or intermittent bolus. He states that the injection is the intermittent bolus and then the catheter is removed. I can see his point, but I always thought these codes are for catheter placed for post-op pain management. For example, the catheter would be placed pre-operatively and then a bolus of pain meds given or even continuously infused later. And, of course, the catheter would not be used as the method of anesthesia for the surgery.

62310 clearly reads NOT via indwelling catheter - so 62318 is the other choice. I just wanted some confirmation that this is correct. The responses seem to bounce back and forth.

Many thanks!

Laura


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## codedog (May 6, 2011)

This forum really got me confused. One coder says this, the other says another. If the doc removes the catheter the same day  seems  like it does not qualify for continous infusion.Does anyone have any  more info on this ?


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## dwaldman (May 15, 2011)

It can stil be a continous epidural infusion with catheter removed the same day. 

62310-62311 is  a single injection.

62318-62319 describes a continous infusion/bolus

The difference in procedure notes and procedures are apparant regardless if the catheter is removed intact the same day.


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