Anesthesia Coding Alert

Check these 3 areas to start coding the ins and outs correctly

Coding for spinal injections might seem simple at first glance, but there are more factors to consider than you might think. Read on for tips on three things you must consider when coding spinal injections.
 
Anesthesiologists are often involved with spinal cases, maybe partly because there are so many options for spinal care: Spinal fusions, laminectomies, diskectomies, and inserting or removing spinal instrumentation are just a few of the most common procedures. Diagnosing and treating spinal pain is also common and is an area anesthesiologists are being called on to help with, especially with the growth of pain management.

Be Sure You Have a Referral

 "Injections to diagnose spinal pain are the single most common pain management procedure," says Cindy Parman, CPC, CPC-H, RCC, owner of the consulting firm Coding Strategies Inc. in Dallas, Ga. "Some physicians perform trigger point injections or prescription management first, but it appears that epidural injections are the preferred venue for diagnosing spinal pain."
 
Tammy Reed, anesthesia department billing manager for Oklahoma University Health Science Center in Oklahoma City, agrees. "The majority of our back pain patients have either trigger point injections or an epidural injection to diagnose back pain," she says.
 
So what brings these patients to the anesthesiologist's door? They all have back pain that other treatments - often prescription or over-the-counter medications, heat or cold therapy, physical therapy, chiropractic care or other modalities - haven't seemed to help alleviate. They may have only dealt with the pain for a few weeks, but most have had back pain for months or even years before visiting the anesthesiologist.
 
"Ninety-nine percent of our patients are referred to us by their primary-care physician or orthopedist because they've already been diagnosed with back pain," says Robin Fuqua, CPIC, certified insurance coder for Jose Feliz, MD, in Escondido, Calif.
 
This referral from another physician is often mandatory - whether the anesthesiologist or the patient's insurance carrier requires it - because sometimes pain is the actual disease to be treated and sometimes pain is a symptom of a bigger problem. The patient's primary-care physician must rule out that the pain is a symptom of a bigger disease before referring the patient to a pain specialist. In fact, most pain physicians won't begin pain treatments until they are assured that there is no treatable cause of the pain or that the pain might be the beginning of worse conditions (e.g., back pain is secondary to an expanding abdominal aneurysm).
 
Some carriers or physicians also have guidelines regarding how long the patient has had pain before he or she can be referred to the pain specialist.
 
"Our patients are referred after they've been in pain for at least three to six months and they are not getting relief from their prescription pain medication," says Terry Garcia, a coder with Tejas Anesthesia in San Antonio.
 
The patient might deal with pain for a long time before a physician determines that it should be treated. Many patients might go through what Parman calls "doctor shopping" while they try to find a treatment that seems to work. That persistence hopefully pays off for the patient in the long run.
 
"We recently saw a patient who had been seeing other doctors for her pain and was treated with narcotics," Reed says. "We performed an ESI (epidural steroid injection) on the second visit, and the patient was pain-free for the first time in years."

Make Sure Medical Necessity Is There

As with other pain management procedures, the physician must document that the patient's spinal injection is medically necessary. Each LMRP has its own set of covered diagnoses and its own instructions for documentation and billing spinal injections, so it's important to check your local policies.
 
Fuqua and Reed point out that Medicare has a specific - and limited - list of acceptable ICD-9 diagnoses to support ESIs. Medicare won't reimburse the physician if the patient's diagnosis isn't on the approved list. That means the patient needs to sign an advance beneficiary notice (ABN) before the procedure that gives the anesthesiologist permission to seek reimbursement from the patient or a secondary insurance carrier if Medicare won't pay.
 
Garcia lists these diagnoses as some of the most common ones their practice sees to justify ESI: