Anesthesia Coding Alert

Spinal injections for pain management can be used in many situations and at a variety of levels. With so many uses available and with the field of pain management and its related codes continuing to grow, selecting the most appropriate code can be a challenge. By examining key areas of the procedure and working with the anesthesia provider, coding professionals can better determine which codes fit each situation best.

Why Is the Injection Done?

The first step to coding a spinal injection correctly is to determine whether it was performed for diagnostic or therapeutic purposes. Diagnostic injections such as code 62270 (spinal puncture, lumbar, diagnostic) are mainly used to help identify sources of pain or infection. Therapeutic injections like codes 64400-64484 (anesthetic injections to somatic nerves), 64505-64530 (anesthetic injections to sympathetic nerves), 64600-64680 (neurolytic injections), or 62310-62311 (non-neurolytic epidural injections) are used to relieve pain or muscle spasms.

For example, a patient may be suffering from back pain that physical therapy or other more conservative treatments may not alleviate. The physician may decide to perform a facet joint injection 64470-64476 (injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; various locations and levels) to aid in diagnosis.

This same patient may be a candidate for a series of injections to relieve the back pain. If so, the individual epidural injections with steroids to treat problems such as sciatica may be coded as 62311 (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] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]).

Other codes that may be used for diagnostic purposes include 62270 (spinal puncture, lumbar, diagnostic) to diagnose infection, or 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]) for lysis of epidural adhesions.

What Is Injected?

Second, the coder needs to know what type of substance was injected: a neurolytic or non-neurolytic substance. These can include neurolytic medications such as phenol, alcohol and iced saline or non-neurolytic medications like anesthetics, antispasmodics and steroids.

Non-neurolytic medications are used for temporary pain relief of low back pain, radiating pain or other problems. These can include codes for combination anesthetic/steroid injections such as 62310-62311 and 62318-62319.

Neurolytics (codes 64600-64680) are used for permanent nerve destruction; they kill the nerve rather than simply numbing it. Because of their permanent nature, neurolytic procedures most often are performed when more traditional forms of pain treatment have not alleviated the patients pain. Administering neurolytics carries more risk for the physician and patient alike. As Scott Groudine, MD, associate professor of anesthesia at Albany Medical Center in New York, says, If you put a local in the wrong place it will wear off. But if you put alcohol or phenol in the wrong place, the patient can have bowel and bladder problems or paralysis. Since it takes a higher degree of certainty before using lytics, they are paid at a higher rate.

Where Is It Injected?

Finally, it is imperative for the coder to know where the injection was administered. Sometimes the most confusion comes from the anesthesiologist failing to specify which area of the spine was targeted, says Charlene Mayle, RN, BSM, practice administrator with the physician group Gulf Anesthesia in Fort Myers, Fla. The anesthesia record may just say treatment for low back pain. We have to know the details of the procedure before we can code it accurately.

In addition to simply knowing the general area where the injection was administered (cervical, thoracic or lumbar level), it also may be necessary to know whether the needle was placed in the epidural space or the subarachnoid space. This can be difficult because although physicians document entry into the epidural space, many providers do not document entry into the subarachnoid space.

Knowing a little basic spinal anatomy will help coders determine the area that was accessed. The protective matter around the spinal cord is made up of three layers the outer layer is the dura mater, the middle layer is the arachnoid, and the inner layer is the pia mater. The epidural space is between the dura mater and the walls of the vertebral canal. The subarachnoid space is between the arachnoid and pia mater and is where the cerebrospinal fluid is located. Physicians often refer to subarachnoid injections as intrathecal or subdural.

Tracking Down the Details

Coding for spinal injections is like coding for any other type of anesthesia procedure the more documentation and details in the patients record, the better. Groudine and Mayle agree that having detailed notes in the operative report is a big help to the coding staff. If the notes are not as specific as you need, dont be shy about asking the provider for more information.

Some of the details you should be sure to include in the patients record are:

1. The specific drug administered (phenol, lidocaine, etc.);

2. The level at which it was administered (L1, L2, T12, etc.);

3. The specific locations for each injection when multiples are administered (whether the injections are unilateral or bilateral, on top of each other, etc.); and

4. The purpose of the injection (which nerve branch is being blocked and why).

The more information the patients record includes about where and why the injection was administered, the better, according to Mayle. If the patient had T12 disk removal years ago, we need to know, she says. That way, we know the block was done below that disk, not above it. The specifics about the case are important to helping be sure we code everything accurately. The details are important in every case, but especially for treatment of long-term care patients or patients on workers comp.

Mayle also will ask the anesthesia providers to provide an addendum to the original dictation in order to get those details. Thats my last resort, she concedes. Blank overall statements about the care just dont give enough information.