# 77003 with 62310-62319 in proposed rule 2015



## dwaldman (Jul 4, 2014)

Based upon our analysis of the Medicare claims data and comments received on the CY 2014 final rule with comment period, it appears that these codes are typically furnished with  imaging guidance.  Thus, we believe it would be appropriate for the injection and imaging guidance codes to be bundled and the inputs for image guidance to be included in the valuation of the epidural injection codes as it is for transforaminal and paravertebral codes. 

Because it is clear that the proposed PE inputs for the epidural injection codes include items that are specifically related to image guidance, such as the radiographic fluoroscopic room, we believe separate reporting of the image guidance codes would overestimate the resources used in furnishing the two services together.  To avoid this situation, we are also proposing to prohibit the billing of image guidance codes in conjunction with these four epidural injection codes.  We believe our two-tiered proposal to utilize CY 2013 input values for this code family, while prohibiting the separate billing of imaging guidance codes in conjunction with epidural injection, would best ensure that appropriate reimbursement continues to be made while we gather additional information and consider the best way to value these services. 

https://www.federalregister.gov/art...schedule-clinical-laboratory-fee-schedule-etc

Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid Innovation Models & Other Revisions to Part B for CY 2015. 

Pages 80-86

2) Epidural Injection and Fluoroscopic Guidance − CPT Codes 62310, 62311, 62318, 62319, 77001, 77002 and 77003 

For CY 2014, we established interim final values for four epidural injection procedures, CPT codes 62310 (Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or 
subarachnoid; cervical or thoracic), 62311 (Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)), 62318 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic) and 62319 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)).  These interim final values resulted in CY 2014 payment reductions from the CY 2013 rates for all four procedures. In the CY 2014 final rule with comment period (78 FR 74340), we described in detail our interim valuation of these codes.  We indicated we established interim final work RVUs for these codes below those recommended by the RUC because we did not believe that the RUC-recommended work RVUs accounted for the substantial decrease in time it takes to furnish these services since the last time they were valued as reflected in the RUC survey data for these four codes.  Since the RUC provided no indication that the intensity of the procedures had changed, we believed that the work RVUs should reflect the reduction in time.  We also established 
interim final direct PE inputs for these four codes based on the RUC-recommended inputs without any refinement.  These recommendations included the removal of the radiographic-fluoroscopy room for 62310, 62311, and 62318 and a portable C-arm for 62319.  We received thousands of comments objecting to the CY 2014 interim final values for these codes, many citing concerns with patient access and with the potential for the payment 
reductions under the PFS to inappropriately incentivize the use of the hospital setting or to encourage the use of other injections.  Some suggested these payment rates might affect the rate of opioid use.  Although most comments did not address the accuracy of the relative value inputs used in determining PFS payment rates, those that did most often objected to our valuations of 
the work RVUs and recommended that we instead accept the RUC recommendations.  Several commenters objected to our rationale for setting the interim final work RVUs lower than the RUC-recommended values primarily based upon the reduction in time.  Commenters gave two   
primary reasons why this reduction was inappropriate.  Some pointed out that a reduction in work based upon a reduction in time presumes that the existing time is correct.  These commenters asserted that the existing times were not correct for these codes.  For example, the RUC noted that the CY 2013 survey times were from the original 1999 survey and were an outlier when compared to the previously reported code?s original Harvard-valued total time of 42 
minutes.  One commenter noted that CMS indicates that in setting work values, the agency considers time, mental effort, professional judgment, technical skill, physical effort and stress due to risk; but in this case, rather than following our process, we only considered time.  Others 
also said that we did not take into account the intensity, complexity, or risk of performing epidural injections.  Commenters disagreed with the use of the lowest RUC survey value as the basis for the work valuation.  One commenter said that we failed to explain adequately why our work RVUs were below those recommended by the RUC.  One recommended that we assign values more similar to those used for paravertebral injections. Two commenters stated that critical PE inputs, including an epidural needle, loss or resistance syringe and spinal needle, were missing from the valuation.  One commenter indicated 
that a radiographic-fluoroscopic room should be included for CPT codes 62310, 62311 and 62318; and a mobile C-Arm should be included for CPT code 62319.  Another commenter requested the decreases in the PE RVUs be phased in over a period of years.  Several commenters objected to the use of the interim final process for valuing these codes, citing the lack of opportunity for public comment and the lack of time to adequately prepare before the cuts to reimbursement took effect.  Some suggested a delay in implementation. 
Lastly, several commenters requested refinement panel review of these codes.   After analyzing the comments and considering valuation of these codes, we believe that we need to reassess our valuation of these codes and require additional information in order to do so.  Our data show that these epidural codes are frequently billed with imaging guidance.  For 
example, CPT code 62310 was billed with CPT code 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)) 79 percent of the time in the nonfacility setting in CY 2013.  CPT code 62319, which is the epidural injection code that is least frequently billed with 
CPT code 77003 in the nonfacility setting, was still billed with this guidance code 40 percent of the time.  These codes were also frequently billed with image guidance in the facility setting.  CPT codes 62310 and 62311 were billed with CPT code 77003, 79 percent and 74 percent of the 
time, respectively in CY 2013.  However, in the facility setting CPT codes 62318 and 62319 were much less frequently billed with CPT code 77003, only 3 percent and 11 percent, respectively.  In addition, these four epidural injection codes are sometimes billed with other fluoroscopic or imaging guidance codes.  Based on the frequency with which these codes are 
reported with fluoroscopic guidance codes, it appears that fluoroscopic guidance is both typically used and typically reported separately in conjunction with the epidural injection services.   As we considered the concerns raised regarding the CY 2014 payment changes for the epidural injection procedures, we looked at the values for other injection procedures.  Other injection procedures, including some recommended by commenters for use as a reference in valuing these epidural injection codes, include the work and PEs of image guidance in the injection code.  For example, transforaminal injections, CPT codes 64479 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or 
CT); cervical or thoracic, single level), 64480 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)), 64483 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or 
CT); lumbar or sacral, single level) and 64484 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)) include the image guidance in the injection code.  Similarly, the paravertebral injections, CPT code 64490 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level), 64491 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or 
thoracic; second level (List separately in addition to code for primary procedure)), 64492 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and 
any additional level(s) (List separately in addition to code for primary procedure)), 64493 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level), 
64494 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for the primary procedure)) and 64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s)( List separately in addition to code for primary procedure)) each include the image guidance bundled in the injection CPT code.   Based upon our analysis of the Medicare claims data and comments received on the CY 2014 final rule with comment period, it appears that these codes are typically furnished with  imaging guidance.  Thus, we believe it would be appropriate for the injection and imaging guidance codes to be bundled and the inputs for image guidance to be included in the valuation of the epidural injection codes as it is for transforaminal and paravertebral codes.  We do not believe the epidural injection codes can be appropriately valued without considering the typical use of image guidance.  We also believe this will help assure relativity with other injection codes 
that include the image guidance.  To determine how to appropriately value resources for the combined codes, we believe more information is needed.  Accordingly, we propose to include CPT codes 62310, 62311, 62318 and 62319 on the potentially misvalued code list so that we can obtain information to support their valuation with the image guidance included.  In the meantime, we are proposing to revert to the CY 2013 input values for CPT codes 62310, 62311, 62318 and 62319 for CY 2015.  Specifically, we will use the CY 2013 work RVUs, work times, and direct PE inputs to establish payment rates for CY 2015.  The work, PE, and MP RVUs for these codes are listed in Addendum B and the time values for all CY 2015 codes are listed in the file ?CY 2015 PFS Work Time,? available on the CMS website under downloads for the CY 
2015 PFS proposed rule at http://www.cms.gov/Medicare/Medicar...nFeeSched/PFS-Federal-Regulation-Notices.html.  The direct PE inputs are displayed the file ?CY 2015 PFS Direct PE Inputs,? available on the CMS website underdownloads for the CY 2015 PFS proposed rule at http://www.cms.gov/Medicare/Medicar...nFeeSched/PFS-Federal-Regulation-Notices.html.  
Because it is clear that the proposed PE inputs for the epidural injection codes include items that are specifically related to image guidance, such as the radiographic fluoroscopic room, we believe separate reporting of the image guidance codes would overestimate the resources used in furnishing the two services together.  To avoid this situation, we are also proposing to prohibit the billing of image guidance codes in conjunction with these four epidural injection codes.  We believe our two-tiered proposal to utilize CY 2013 input values for this code family, while prohibiting the separate billing of imaging guidance codes in conjunction with epidural injection, would best ensure that appropriate reimbursement continues to be made while we gather additional information and consider the best way to value these services.  With regard to comments about the time for responding to the interim values, we would 
refer to section II.F of this proposed rule, which discusses a proposal to make changes in the process used for establishing revised values for codes such as these.   With regard to the request for refinement, we are denying this request as the comments do not demonstrate that the requirements for refinement were met.  Moreover, since we are proposing different values for these codes for CY 2015 (using CY 2013 inputs) there would be no purpose for refinement as the public comment period for this proposed rule will provide the 
opportunity for the public to share any relevant information on our proposed values.


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