Anesthesia Coding Alert

Interventional Pain Management:

Combat Denials by Changing TOS to 09

Published on Fri Feb 13, 2004

As the pain management field continues to grow, so do the specialty areas within the field. One important specialty is interventional pain management, with specialists trained to perform delicate procedures such as fluoroscopy, SI joint injections and diskography. The following tips can help you determine how to accurately report interventional pain management services.

Know What Falls Under Interventional PM

Pain specialists are board-certified physicians who study pain and perform manipulations and small injections (such as 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). Because interventional pain management specialists complete fellowships and additional training, plus pass additional board-certification exams, their scope of practice is slightly different.

"Medicare recognizes interventional pain management as a separate specialty," says Abraham Rivera, MD, CEO of Pain Management Medical Group in Albany, N.Y. "However, Medicare and some other carriers usually won't change the practitioner's designation to interventional pain management specialist (Type of Service - or TOS - 09) unless he or she is board-certified by at least one of the certifying bodies."

After the carrier designates the practitioner as an interventional pain management specialist, your practice can collect reimbursement for procedures for which other physician specialties (such as anesthesiologists or neurologists) can't collect.

Rivera and Laxmaiah Manchikanti, MD, president and executive director of the American Society of Interventional Pain Physicians (ASIPP) in Paducah, Ky., cite several procedures as examples of the types of services interventional pain specialists perform:

Fluoroscopy. CPT lists several fluoroscopy codes, but interventional pain specialists use 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) most often.

You must use caution, however, when reporting fluoroscopy, Rivera says. "The rule is that if you're doing fluoroscopy strictly for needle placement, then code 76005 applies in addition to the codes for the epidural, spinal or articular injections," he says. "The only exception is a RACZ procedure, where everything is included and you cannot unbundle the fluoroscopy part." (Report RACZ procedures with either 62263, Percutaneous lysis of epidural adhesions using solution injection [e.g., hypertonic saline, enzyme] or mechanical means [e.g., catheter] including radiologic localization [includes contrast when administered], multiple adhesiolysis sessions; 2 or more days, or 62264, ... 1 day.)

Spinal injections. Report 62280 (Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; subarachnoid), 62281 (... epidural, cervical or thoracic) or 62282 (... epidural, lumbar, sacral [caudal]), for spinal injections, depending on the injection site.

Facet injections. Codes 64470-64476 describe various sites and levels associated with paravertebral facet joint and facet joint nerve injections.

Epidural injections. Use 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] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62311 (... lumbar, sacral [caudal]) for single injections for these procedures.

Report 62318 (Injection, including catheter placement, continuous infusion or intermittent bolus, 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; cervical or thoracic) or 62319 (... lumbar, sacral [caudal]) for continuous administration. Use the appropriate code from 64479-64484 (various sites and levels associated with Injection, anesthetic agent and/or steroid, transforaminal epidural) for transforaminal epidurals.

SI joint injections. Report 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid) for SI (sacroiliac) joint injections. You should report 27096 only if the physician documents imaging confirmation of intra-articular needle positioning. "Well-intended practitioners commonly inject the SI joint 'blindly' in the office," Rivera says. "But it's hard to accurately inject the SI joint even with fluoroscopy, so to pretend we can 'inject' the SI joint blindly is wishful thinking. If you're using code 27096, you must do it with fluoroscopy and have a picture to prove it."

Diskography. Report 72285 (Diskography, cervical or thoracic, radiological supervision and interpretation) or 72295 (Diskography, lumbar, radiological supervision and interpretation) for diskography services.

Catheter implantation. If the pain management interventionalist implants a catheter for drug infusion, you should report 62360 (Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir).

Intradiskal therapy. Report 62287 (Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar [e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy]) for disk decompression or aspiration.

Don't Drop Modifiers for Treatments

Many common interventional pain management treatments qualify for modifiers that help explain special circumstances and help the provider achieve appropriate reimbursement. Keep these four common modifiers in mind when you're filing your next claims:

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) - Use modifier -25 for situations such as appending it to the appropriate E/M code if the physician administers a pain management injection during a standard E/M visit.

Modifier -50 (Bilateral procedure) - Many carriers now require this modifier for facet injections. Remember that when you report modifier -50 you should be reimbursed 150 percent for the procedure.

Modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) - Be sure to add this modifier the first time a patient comes in for a pump refill.

Modifier -59 (Distinct procedural service) - Use modifier -59, for example, when you report a nerve block placed for postoperative pain management on the same day as the original procedure.

Let Carriers Know You Have Certification

If your physicians are certified to perform interventional pain management procedures, you should complete the paperwork required to change your designation from anesthesia (TOS 07) to interventional pain medicine (TOS 09). Submit a Form 855I to CMS (download it from CMS' Web site at http://cms.hhs.gov/providers/enrollment/forms/). You don't need to complete the entire form if you're already a CMS provider because you require an update, not an initial enrollment. Instead, you should complete the general application information, practitioner information and certification statement (signature page).

In the Practitioner Information section, subsection E (Medical Specialties), part 1 (Physician specialty), write "Interventional pain management - 09" in the blank space provided under "Undefined physician type." Then submit the form to CMS and get ready to begin reporting TOS 09 on your claims.

Changing your physician specialty may not end all of your pain management denials, but it can help you recoup reimbursement for those big-ticket procedures. "The high-end procedures are the crux of the issue," Rivera says. "Most carriers don't argue over trigger point injections or most E/M codes with either specialty designation. Reimbursement problems come with morphine-pump implantations, dorsal column stimulators, neurolytic procedures and percutaneous disk decompressions. If you provide these services but haven't changed your specialty designation to 09, you won't be paid."

Interested in NCCI edits for interventional techniques? E-mail editor Leigh DeLozier at leighdelozier@bellsouth.net for a handy chart to help you pinpoint some commonly bundled procedures.