Anesthesia Coding Alert

With only two choices available, coding fluoroscopy associated with nerve blocks or destruction should be straightforward. However, the two options are a challenge: 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) and 76005 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).

Code 76005 was introduced in CPT 2000 but is still a new code to many of us, according to Carla Thibodeaux, CPC, an anesthesia coder with the 75-anesthesiologist group Tejas Anesthesia in San Antonio. So many new pain codes were introduced last year that were still learning which to use when. Weve been so accustomed to using 76000 for any fluoroscopy that its sometimes hard to remember that we cant automatically code that way anymore. Now we have the challenge of picking apart the procedure notes to determine which fluoroscopy codes go with which procedures.

Use Location as Coding Clue

The injection location is the primary clue for determining which fluoroscopy block code is accurate. For example, if the injection is administered to any area of the spine, including the sacroiliac joint, use 76005. If the block is administered to an area other than the back, use code 76000. Examples follow:

Intercostal nerve blocks, brachial plexus blocks and stellate ganglion blocks fall under 76000 because they are all pain procedures.

Lumbar, paravertebral or sacroiliac joint blocks to treat back pain are coded with 76005. Including sacroiliac joint injections with code 76005 might confuse some coders, Thibodeaux says, because they dont think of the sacroiliac joint as part of the spine.

Revision or removal of peripheral neurostimulator electrodes (64585) is a procedure that falls under fluoroscopy 76005.

For nerve blocks, common procedural codes to bill along with 76005 include 64470-64484 (codes related to various levels and sites of injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve). Codes 64400*-64450* (codes related to different nerves for injection, anesthetic agent) still go with 76000.

Consider More Coding Contingencies

Epidurography: This procedure presents another anesthesia coding challenge. The primary ASA code for anesthesia during an epidurography (72275, epidurography, radiological supervision and interpretation) is 01922 (anesthesia for noninvasive imaging or radiation therapy). Two other coding options depend on the anesthesiologist. If it is determined that it would not be a routine procedure, append modifier -23 (unusual anesthesia). And, if either the surgeon or anesthesiologist chooses MAC for the procedure, you would have to code accordingly.

You must file a formal report to submit codes 76005 or 76000 with 72275. But, because an epidurography is a radiological procedure, there might be enough information in the radiology report to cover billing 76000.

Modifiers: Robin Fuqua, CPIC, a certified insurance coder with the physician group Anesthesia Consultants of California in Escondido, Calif., says her group often uses its surgical centers equipment for fluoroscopy, therefore coders append procedural codes with modifier -26 (professional component) to indicate that the physician is charging for services only. The only time we have a problem with this coding is if we accidentally bill Medicare Part B without the -26 modifier, Fuqua says. If the modifier isnt included, the carrier infers that were billing for equipment use which should be billed to Medicare Part A and denies the claim.

Physicians Report: Fuqua also reminds coders that, to justify the additional code, the physicians report must state that the injection was performed with fluoroscopy. Dont overuse fluoroscopy because Medicare is watching for that type of abuse, she warns. Only use fluoroscopy with the procedure if the patients complications make it difficult to achieve pinpoint accuracy without it. And, always, always strongly document the need for fluoroscopy.

Coding fluoroscopy along with nerve block or destruction codes has so many options and subtleties that Thibodeaux notes right in the coding reference books which codes to use when.

Make Sure to Think About Bundling

Fluoroscopic blocks are often performed in conjunction with other procedures, so youll need to know when the two services are bundled and when they can be billed separately, Fuqua says. For example, destruction code 64620 (destruction by neurolytic agent, intercostal nerve) is not bundled with the fluoroscopy component, so you can bill 76000 in addition to 64620. The same is true for codes 64600, 64605 and 64610 (destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch; second and third division branches at foramen ovale; second and third division branches at foramen ovale under radiologic monitoring), although Thibodeaux reports she rarely sees these codes applied.

On the other hand, procedures such as 62284* (injection procedure for myelography and/or computerized axial tomography, spinal [other than C1-C2 and posterior fossa]) and 62263 (percutaneous lysis of epidural adhesions using solution injection [e.g., hypertonic saline, enzyme] or mechanical means [e.g., spring-wound catheter] including radiologic localization [includes contrast when administered]) are already bundled with the fluoroscopic component, so payers will not reimburse both procedures if you bill them separately. Thibodeaux advises you to choose one coding reference as your primary guide and check with your carrier, because its bundling policy might differ.