# flouroscopic guidance denial



## kimmcelderry@gmail.com (Jun 12, 2020)

Hi there, I am not very familiar with billing in pain management procedures and we received a denial I am unsure about. We billed in this order:
77002-59 ( all with G58.8)
64420-RT
64421-RT
J1020

The denial states "the related or qualifying claim/service was not identified on this claim"   
I have looked everywhere, but don't see any exclusions on billing these codes together. Can anyone offer any insight?

Thank you


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## SharonCollachi (Jun 12, 2020)

I think you're using the wrong fluoro code, which is why it was denied.  It should be 77003.  I don't believe you need the modifier 59 (but it's been a hot minute since we stopped doing these in our office procedure room).

I'm assuming you are doing this in an office-based procedure room, and not at an ASC or other facility (because if so, you would just bill the 64420s and the facility would bill the rest).

I always put the fluoro last on the claim, putting the main procedure first. And you are using contrast, correct?  You get to bill that too.  We were using Omnipaque, which is Q9965; if you're using something else, check for the HCPCs code.

Are you doing moderate sedation?  You get to bill that as well.  My version of the CPT book has a nice chart on page 751 showing how to choose the mod sedation codes.  They start with 99151.  We used fentanyl (J3010) and versed (midazolam - J2250) in the sedation cocktail, and you get to bill those also. Some people use propofol (J2704) or other meds.


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## kimmcelderry@gmail.com (Jun 12, 2020)

Thank you so much for your answer, Sharon! It seems so clear to me now lol.  I don't see any dictation regarding sedation, but I will keep that in mind in the future.


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## thomas7331 (Jun 12, 2020)

Actually, both 77002 and 77003 are add-on codes that are not approved by CMS for use with either 64420 or 64421.  You can find the list of allowable base codes for each of these here:



			https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits
		


You've billed two injection codes that already include fluoroscopic guidance under NCCI, but have billed a modifier 59 which indicates that the guidance is unrelated to those codes.  However, you have no other procedure to which this related, so I believe the guidance is likely reported in error here.  Also, are you sure that the documentation supports both 64420 & 64421?  The first is for a single injection and the second is for multiple injections at the same region, but the RT modifiers suggest that these were injections on the same side.


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## SharonCollachi (Jun 12, 2020)

thomas7331 said:


> Actually, both 77002 and 77003 are add-on codes that are not approved by CMS for use with either 64420 or 64421.  You can find the list of allowable base codes for each of these here:
> 
> 
> 
> ...



I'm not seeing where those two codes include fluoro guidance.  In that section, CPT as well as CPT Coding Essentials Anesthesia and Pain Management 2020 says 64400-64450 may have imaging guidance/localization billed spearately. Or is this one of those where Medicare says "we don't care what CPT says, we're doing this anyway"?  Although we don't know that the insurance was Medicare.


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## kimmcelderry@gmail.com (Jun 12, 2020)

thomas7331 said:


> Actually, both 77002 and 77003 are add-on codes that are not approved by CMS for use with either 64420 or 64421.  You can find the list of allowable base codes for each of these here:
> 
> 
> 
> ...



The procedure was for Rt T2, T3, T4, and T5 intercostal nerve blocks. So guess we should only be billing 64421?


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## thomas7331 (Jun 12, 2020)

kimmcelderry@gmail.com said:


> The procedure was for Rt T2, T3, T4, and T5 intercostal nerve blocks. So guess we should only be billing 64421?



That would be my understanding, though pain management isn't really my area of specialty and without seeing the documentation I hesitate to say.  

But per the Coders' Desk Reference:  _In 64420, a single injection is performed. In 64421, multiple nerves are injected to provide pain relief to a larger area (regional block). _


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## josephmglick (Jun 28, 2020)

64420 is for a single level;* Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level* 
and 64421 is and add on code to 64420; *Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (List separately in addition to code for primary procedure) *
In your CPT book look for 77002 and there should be a notation as to what codes it is allowed to be billed with it. I don't see these codes as being allowed on that list.

Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)
(See appropriate surgical code for procedure and anatomic location)

(Use 77002 in conjunction with 10160, 20206, 20220, 20225, 20520, 20525, 20526, 20550, 20551, 20552, 20553, 20555, 20600, 20605, 20610, 20612, 20615, 21116, 21550, 23350, 24220, 25246, 27093, 27095, 27369, 27648, 32400, 32405, 32553, 36002, 38220, 38221, 38222, 38505, 38794, 41019, 42400, 42405, 47000, 47001, 48102, 49180, 49411, 50200, 50390, 51100, 51101, 51102, 55700, 55876, 60100, 62268, 62269, 64400-64448, 64450, 64455, 64505, 64600, 64605) 

I believe it should look like the following:
64420
64421 x3
J code


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## thomas7331 (Jun 29, 2020)

Yes, agree with the above.  I see that 64421 was revised in 2020 to make it an add-on code now, so the Coders' Desk Reference guidance I cited in my last post is now out of date.


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## bwoerner (Jul 28, 2020)

I believe you would also bill 77002 with 64420 and 64421 X3 . It is included within the "64400-64448"  code set in the below note .


 (Use 77002 in conjunction with 10160, 20206, 20220, 20225, 20520, 20525, 20526, 20550, 20551, 20552, 20553, 20555, 20600, 20605, 20610, 20612, 20615, 21116, 21550, 23350, 24220, 25246, 27093, 27095, 27369, 27648, 32400, 32405, 32553, 36002, 38220, 38221, 38222, 38505, 38794, 41019, 42400, 42405, 47000, 47001, 48102, 49180, 49411, 50200, 50390, 51100, 51101, 51102, 55700, 55876, 60100, 62268, 62269, 64400-64448, 64450, 64455, 64505, 64600, 64605)


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## myasworld1@gmail.com (Aug 1, 2020)

u





kimmcelderry@gmail.com said:


> Hi there, I am not very familiar with billing in pain management procedures and we received a denial I am unsure about. We billed in this order:
> 77002-59 ( all with G58.8)
> 64420-RT
> 64421-RT
> ...


77002 is an add on code, that should not have been listed first or used. 64420 should be listed first. The claims are processed electronically it's gonna kick it out. It is not able to identify the main procedure submit a corrected claim so you do not use your appeal rights


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