Anesthesia Coding Alert

3 areas will make or break your claims

With facet injections often considered the "meat and potatoes" of pain management practices, you must understand and code them correctly. Read on for tips on the three areas you can't afford to overlook when coding these injection services and for the rules of the road for submitting these claims to different carriers.

Start With the Right Codes

Each vertebra is associated with four facet joints - one pair that faces upward and one pair that faces downward. The facets interlock with the adjoining vertebrae and provide spinal stability. Facet injections  target either the nerves running above and below the facet joints or the joint itself.

Code selection begins by knowing what the physician injects. Here are the four CPT codes that represent facet injections when he injects an anesthetic or steroid:
 

64470 - Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level (10 relative value units [RVUs])
 

+64472 - ... cervical or thoracic, each additional level (list separately in addition to code for primary procedure) (5 RVUs)
 

64475 - ... lumbar or sacral, single level (8 RVUs)
 

+64476 - ... lumbar or sacral, each additional level (list separately in addition to code for primary procedure) (4 RVUs).

You have four additional codes to select from when the physician performs neurolysis of the facet level:
 

64622 - Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level (12 RVUs)
 

+64623 - ... lumbar or sacral, each additional level (list separately in addition to code for primary procedure) (6 RVUs)
 

64626 - ... cervical or thoracic, single level (12 RVUs)
 

+64627 - ... cervical or thoracic, each additional level (list separately in addition to code for primary procedure) (6 RVUs).

Count them: When you code for facet injections, bill for the number of levels injected, says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.

For example, an anesthetic or steroid injection to the L3/L4 and L4/L5 joints equals two levels. Report the procedure with 64475-64476 (report 64622-64623 for a neurolytic injection).

Caution: Coding can be tricky when the procedure involves both thoracic and lumbar vertebrae, such as a T12/L1 injection. Opinions on how to code this procedure vary. Check the documentation and talk with the physician if you have questions, but Bukauskas-Vollmer says you would probably code it by the thoracic level (64470 or 64626). The patient's diagnosis - whether the physician is treating thoracic or lumbar pain - might help you determine the correct code.

Verify Bilateral Details

Because the facet joints are on either side of the vertebrae, physicians often perform bilateral facet injections. Before coding these cases, verify whether the carrier requires modifier -50 (Bilateral procedure) or modifiers -LT (Left side) and -RT (Right side) to designate bilateral injections.

"Most carriers want modifier -50 for bilateral procedures," Bukauskas-Vollmer says. "Modifiers -LT and -RT are used when the physician performs different procedures on either side. Some medical societies recommend reporting both modifier -50 and -LT/-RT, but I feel that's redundant."

Most carriers recognize modifier -50 and reimburse it at 150 percent of the procedure price. That means the provider receives 100 percent reimbursement for the first injection and 50 percent for the second.

Code it: If the L4/L5 injection noted above is a bilateral procedure, code the first injections on either side as 64475, 64475-50 and each second injection as 64476. How you report each injection on the claim depends on the carrier's preference.

For example, CMS wants coders to report bilateral procedures on one line with modifier -50 and the payment listed at 150 percent of the allowable amount. Other carriers want you to bill bilateral procedures on two lines The most important thing is to know each carrier's reporting requirements:
 

For CMS, report 64475-50 on line 1 and 64476 x 2 on line 2.
 

For some other carriers, report 64475 on line 1, 64475-50 on line 2, and 64476 x 2 on line 3.
 

Still other carriers accept 64475-50 on line 1 and 64476-50 on line 2, says Sharon Ryan, CPC, coder with Anaesthesia Associates of Massachusetts in Westwood.

Key: Bilateral procedures must be mirror images of each other. The physician must perform the same injections at exactly the same location on both sides before you can report the procedure with modifier -50.

Double-Check NCCI Edits

In addition to watching your reimbursement levels for facets, keep a close check on the quarterly National Correct Coding Initiative (NCCI) edits.

NCCI bundles trigger point injections (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]; and 20553, ... single or multiple trigger point[s], three or more muscles) and many other procedures with facet joint injections when the physician performs them during the same session. That means you can't report both procedures and append modifier -51 (Multiple procedures). Instead, you report whichever code from the bundled pair is considered to be the "comprehensive" code, because the other procedure is considered part of it.

Hint: NCCI edits, however, do not bundle facet injections with fluoroscopic guidance (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). Using fluoroscopic guidance with facet injections is standard practice, so be sure to report both services.

Know the Medical-Necessity Requirements

"It's important to have full documentation of medical necessity for facet injections because most practices perform so many of them," Bukauskas-Vollmer says. "Verify each carrier's documentation requirements so you'll submit the correct paperwork - some want documentation similar to operative notes with the full diagnosis and other information."

Final tip: Always obtain prior approval if you have any doubts about the carrier accepting the diagnosis for the procedure.