# Billing 77003 with 27096 & 62311



## mgrimaldi

When a physician bills a SI joint injection (27096) and a Lumbar ESI (62311) at L5-S1 are people billing for the 77003 to cover the use of fluoro for the LESI?  I know it is bundled with the SI joint injection, but should providers get reimbursed seperately for the use of it in the ESI injection?  Thoughts?


----------



## mcnaryk

mgrimaldi said:


> When a physician bills a SI joint injection (27096) and a Lumbar ESI (62311) at L5-S1 are people billing for the 77003 to cover the use of fluoro for the LESI?  I know it is bundled with the SI joint injection, but should providers get reimbursed seperately for the use of it in the ESI injection?  Thoughts?



I've always been taught that we can't bill seperately for the fluoro for the ESI because it's included in the SI-which doesn't seem right since the fluoro is directed to different areas for each injection, but I have never seen insurance pay for it's seperate use. Anyone else have some experience with this? Great question!


----------



## dwaldman

I just sent your question to the AMA CPT Network, another resource would also to write NCCI. I will try to follow with how they respond because I have wonder this myself when seeing a similar post.




Question Type: General CPT Coding Question 


Question:
 When a physician performs s a SI joint injection (27096) under fluroscopic guidance and a Lumbar intralaminar epidural (62311) at L5-S1 also under fluoroscopic guidance , is appropriate to report CPT 77003 to cover the use of fluoroscopy for the lumbar intralaminar epidural?  


Response:


----------



## aaron.lucas

I would think that if the injections are in the same region of the spine then NCCI edits would dictate no.  BUT, if the 62311 was at a different region (or if they did 62310 and the SI), then 77003 could be billed with a -59 to show "separate anatomical location" to override the NCCI edit.  I say region because flouro is billed per region, not per level.  I would be interested what AMA has to say though...


----------



## MarcusM

ODG states: "Fluoroscopy (for ESI's): Recommended. Fluoroscopy is considered important in guiding the needle into the epidural space, as controlled studies have found that medication is misplaced in 13% to 34% of epidural steroid injections that are done without fluoroscopy. " 

from  http://www.aaos.org/news/aaosnow/apr12/managing1.asp

Epidural injection: The surgeon performs an epidural injection at L4-5 in a patient with chronic back and leg pain. The documentation states that fluoroscopic guidance was used for needle placement, and that contrast was injected, and it was confirmed that the needle tip was in the epidural space. Steroid injection was performed. The procedure was performed in the ASC.
Coding is as follows:
62311—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.
77003-26—Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid).
Fluoroscopic imaging is separately reportable because the injection code does not include the image guidance in the description. Because the procedure was performed in a facility setting, CPT code 77003-26 is reported for the professional interpretation only. For the same reason, the drugs are not reportable by the physician.


----------



## dwaldman

The below can be found in AMA CPT Assistant Sept 2004. The reason I am sending to the AMA for clarification is if the SI joint is in the sacral region and an intralaminar injection is at lumbar region, technically you would span two spinal regions so would they consider reporting 77003 in conjunction with an epidural and a code such as 27096 were the fluoroscopy is valued and included in the code.

Coding Tip

Code 76005 is intended to be reported per spinal region (eg, cervical, lumbar) and not per level. 

Below is the question that I plan to send to NCCI to have both the NCCI/CMS and AMA perspective:

National Correct Coding Initiative
Correct Coding Solutions LLC
P.O. Box 907
Carmel, IN 46082-0907

Attention:  Niles R. Rosen, M.D., Medical Director and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist


After reviewing the below statement in chapter 9 in the NCCI policy manual, I was inquiring about when a sacroiliac joint injection in the sacral region is performed with fluoroscopy (27096) at the same encounter as lumbar intralaminar injection (62311) at L5-S1 with fluoroscopic guidance (77003). Would it be appropriate to add modifier 59 to 77003 since the fluoroscopic guidance was utilized for the performance of the lumbar epidural at a separate site in addition to the sacroiliac joint injection that also requires fluoroscopy. Since fluoroscopy is only reported once per session, how does this concept apply when there is a code that includes and requires fluoroscopy performed in the same encounter as a code that fluoroscopy is separately reportable?
3. CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities.  CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed.  The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.


----------



## dwaldman

Code 62311 is a component of Column 1 code 27096 but a modifier is allowed in order to differentiate between the services provided. 

I guess I have also include in the question if the 59 modifier is appropriate to add 62311 for an intralaminar injection when performed during the same setting as 27096 since I have not seen these procedures performed together during the same encounter I was unaware there was bundling issue.


----------



## KMCFADYEN

dwaldman, I would be very interested in the responses you receive.
kelly@egglestonandeggleston.com


----------



## dwaldman

Below is from the AMA CPT Network regarding 27096 performed with 62311 77003

"........it would be appropriate to report code 77003, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid), when used to place a needle for a lumbar epidural steroid injection (62311)."


I still in the process of receiving the NCCI response that could differ from above do to their bundling edits but might be supported to be bypassed do to the separate anatomical site. Will follow up with that response.


----------



## mgrimaldi

dwaldman, Thanks for following up on this.  I will wait to hear the response you get regarding the CCI edits.


----------

