Anesthesia Coding Alert

The Federal Drug Administration (FDA) cleared IntraDiscal Electrothermal Therapy (IDET) in 1998 to treat patients with chronic diskogenic pain, but many insurance carriers are still unfamiliar with it. There is no CPT Codes for the procedure, and this adds to the challenge anesthesia providers face when attempting to get reimbursed. Practices that work with their local carriers to gain preapproval for the procedure and understand the accepted codes for it will have a more successful reimbursement track record.

What Leads to IDET?

Tears or fissures may develop in the walls of intervertebral disks as you age. These tears can become a source of chronic pain. The inner disk tissue sometimes can herniate into the fissures, which stimulate pain sensors in the disk and add to the patients discomfort.

Before doing an IDET procedure, the patient must be diagnosed with diskogenic pain (722.0-722.9). For example, a patient may have low back pain for months or years that radiates into his buttocks or tailbone but with very little radiation down the leg. In time, the patients physician may decide to take the next step to determine whether he has diskogenic pain.

The next step toward that diagnosis is a magnetic resonance imaging (MRI) performed by a radiologist. These codes are 72148-72149 and 72156-72158. The MRI shows whether the disk has signs of wear and tear or degenerative changes. Disks that cause pain usually show a loss of water content, and the radiologist may find a tear in the disk or other evidence of damage during the MRI.

If the MRI shows changes in the disk, physicians possibly would prescribe physical therapy, depending on how severe the patients pain is and how damaged the disk is. A series of pain management injections (20550, 64475, 64476, 64483, 64484, 62280, 62282, 62311) also may be prescribed before taking the patients treatment to the next level.

If these conservative therapies dont help the patients pain, the physician will perform diskography, which is recognized as the gold standard for making a disk-related diagnosis. A needle is placed in the patients disk by an anesthesiologist or neurosurgeon, and physiological pressure is created to represent the actual tension the disk is under when the patient is sitting or standing. Dye is injected during the test that fills cracks and allows the physician to see tears in the disk.

Cecelia McWhorter, BA, CPC, a coder with the physician billing agency Comp One Services Ltd. in Oklahoma City, says the injection procedure for diskography should be billed using either code 62310 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s], epidural or subarachnoid; cervical or thoracic) or 62311 (injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast, of diagnostic or therapeutic substance, epidural or subarachnoid; lumbar, sacral). The radiological supervision and interpretation of diskography should be coded using 72295 (diskography, lumbar, radiological supervision and interpretation) with modifier -26 (professional component)

Who Is IDET Candidate?

The patient becomes a candidate for IDET once the physician determines that one or two disks are causing the pain, says McWhorter. IDET is a minimally invasive outpatient procedure during which the physician applies thermal energy (or heat) to a section of the affected disk wall through a flexible catheter. The catheter rests along the injured area of the disk wall, generating heat that contracts and thickens the disks collagen. This causes the fissures to close or contract and alleviates low back pain.

Because there is not a specific CPT code for IDET, different carriers may prefer different codes for reporting the procedure. Barbara Johnson, a professional coder at Loma Linda University, Anesthiosology Medical Group Inc. and president of Real Code Inc., in California, recommends billing with the following codes based on discussions with Oratec Interventions, the Menlo Park, Calif., company that makes the SpineCATH catheter used during IDET.

62287 (aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar) for the procedure itself

64640 (destruction by neurolytic agent, paraver- tebral facet joint nerve; other peripheral nerve or branch) for thermal destruction

76005 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures, including neurolytic agent destruction) with
modifier -26

72295 (diskography, lumbar, radiological supervision and interpretation) with modifier -26

Individual carriers also may consider other codes to be appropriate for IDET. For example, McWhorter says the Medicare carrier in Oklahoma recommends filing with 64999 (unlisted procedure, nervous system) because there is no code specifically for IDET in CPT 2000. This is also the code recommended by the American Medical Association (AMA). Coders in other states such as Wisconsin say they have problems getting reimbursed when IDET is billed with 64999.

Some physicians may give the patient an antibiotic injection during the procedure to prevent complications. If so, you also should bill 62311 with modifier -58 (staged or related procedure or service by the same physician during the postoperative period).

If the carrier denies surgical codes for anesthesia procedures, then use codes 00600 (anesthesia for procedures on cervical spine and cord; not otherwise specified), 00620 (anesthesia for procedures on thoracic spine and cord; not otherwise specified), 00630 (anesthesia for procedures in lumbar region; not otherwise specified), or 00300 (anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified). Any of these codes could also be amended with modifier -52 (reduced services). When all else fails, try code 01999 (unlisted anesthesia procedures). Be sure the code is backed up with complete documentation that clearly explains the services performed.

Preapproval Saves Time

Although IDET was approved two years ago, many insurers still believe it is an investigational or experimental procedure and may not pay for it. Coding professionals who are dealing with the procedure find that getting preapproval can make a big difference in reimbursement.

About 10,000 IDET procedures have been performed since 1998. McWhorter says many physicians have stopped performing the procedure due to reimbursement problems, but working with diskogenic codes and seeking preapproval should assist in reimbursement efforts.