Anesthesia Coding Alert

Pain management coders won't be able to miss the new edits the Correct Coding Initiative (CCI) has included for fluoroscopic guidance. If you're not up on the changes in version 16.1, you may try to separately report fluoroscopic guidance. The new bundling edits won't allow as of April 1, 2010.

Version 16.1 is the second CCI update of the year. This version includes 2,054 new active pairs and 1,947 modifier changes, says Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions, Inc. in Clearwater, Fla. Here's what you need to know about the top 16.1 edits that will affect your pain management practice.

Version 16.1 bundles one fluoroscopic needle guidance code -- 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) -- into several pain management procedures.

Some you might expect and some may surprise you. One new bundle won't let you report 77002 with 62267 (Percutaneous aspiration within the nucleus pulposus...). CPT includes a parenthetical note directing providers to report 77003 (Fluoroscopic guidance for localization of needle or catheter tip for spine or paraspinous procedures...) for image guidance for 62267so the new edit bundling 77002 as a column 2 code into 62267 makes sense, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver.

Check it out: CCI 16.1 also includes edits that bundle 77002 as a column 2 code into both 62268 (Percutaneous aspiration, spinal cord cyst or syrinx) and 62269 (Biopsy of spinal cord, percutaneous needle). Both of these column 1 codes include a note in the 2010 CPT codebook directing providers to use 77002 for radiologic guidance.

The new version also includes bundling edits between 77002 and several of the neurolytic destruction codes, including 64620 (Destruction by neurolytic agent, intercostal nerve).

Code 77003 is also bundled as a column 2 code into many of the autonomic nerve injection codes, such as 64510 (Injection, anesthetic agent, stellate ganglion [cervical sympathetic]).

Beware: "With these new CCI edits, if the physician only performs the column 1 pain management procedure code along with the column 2 fluoroscopic guidance, it would not be compliant to append a modifier to bypass this edit," Hammer says.

One example of the importance of swapped pairs in CCI 16.1 occurs with greater occipital nerve (GON) injections. If your pain management specialist performs an injection on a patient's GON (64405, Injection, anesthetic agent; greater occipital nerve) and also performs a tendon injection in a separate anatomic location, such as the thumb for De Quervain's syndrome (20550, Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]), you'll need to know that the two codes have switched places.

The result: As of April 1, 20550 is now the column 2 code, with 64405 in column 1. "It makes more sense, because you don't do greater occipital nerve injections as an anesthetic for the tendon injection," Hammer says. This edit carries a "1" modifier indicator.

Reminder: A modifier indicator of "0" means that you cannot unbundle or break the pair with any modifier. A modifier indicator of "1" means that you  may be able to unbundle if medical necessity calls for it.

Be sure you have the proper documentation from your pain management specialist's notes, says Eman Danial, CPC, billing manager with Westgate Pain Management Group in Cleveland. With this new switch, the new column 1 code will be processed for payment, while 62365 will be denied.

Reasoning: The logic behind this kind of CCI edit is that the more extensive procedure is now in column 1.

You should now check CCI for swaps involving 64450 (Injection, anesthetic agent, other peripheral nerve or branch). For example, check when your pain management specialist performs a sacroiliac ligament injection, reported with 20550 or an ulnar nerve block at the elbow for cubital tunnel syndrome (354.2, Lesion of ulnar nerve).

Due to the new swap, you now need to append the modifier to bypass the CCI edit to the ligament injection code 20550 rather than 64550. By appending modifier 59 (Distinct procedural service)you're indicating that they physician performed the injections in different anatomic locations.