Anesthesia Coding Alert

Lumbar Lowdown:

Follow These 3 Steps to Clean Lumbar Plexus Block Claims

Published on Tue May 17, 2005

Plus: The secret to differentiating lumbar sympathetic destructions

When you code for a specialty whose procedures are concentrated in a specific area - such as the lumbar region - you can have a hard time keeping the procedural terminology and corresponding codes straight. Our experts teach you a simple three-step strategy for avoiding this confusion when reporting the different types of diagnostic and therapeutic lumbar procedures.

1. Understand the Differences

Many lumbar pain management procedures fall into one of two categories: diagnostic and therapeutic blocks (by single-shot injection or continuous infusion catheter), and destruction/ablation by a neurolytic agent. Your first step in coding correctly is being able to identify each type of service.

Blocks. A physician usually administers a block to provide temporary pain relief for the patient. Some blocks can provide permanent pain relief, as with reflex sympathetic dystrophy patients, says Scott Groudine, MD, an Albany, N.Y., anesthesiologist. Blocks can be single-shot injections or continuous infusion and can be either diagnostic or therapeutic, depending on the circumstances.

Many coders say their physicians administer lumbar blocks for therapeutic reasons more often than as diagnostic tools. Common diagnoses supporting medical necessity for diagnostic blocks include 724.4 (Thoracic or lumbosacral neuritis or radiculitis, unspecified), 724.02 (Spinal stenosis, lumbar region), 722.10 (Displacement of lumbar intervertebral disc without myelopathy) and 724.3(Sciatica).

Nerve destruction/ablation. A physician prescribes destruction to completely "kill" the nerve causing the patient's pain. He uses a chemical, thermal, electrical or radiofrequency agent to achieve the destruction.

Nerve destruction (also known as "denervation") is often one of the physician's last resorts for pain management after other techniques have failed, says Barbara Johnson, CPC, MPC, owner of the consulting firm Real Code Inc., in Moreno Valley, Calif. The complete destruction can be accomplished in one session or over a period of days, but Johnson and Groudine agree that one injection is usually sufficient.

"Most anesthesiologists would not perform neurolysis for trivial pain," Groudine says. "Once alcohol is put on a nerve, that nerve may never function again. Most people use it when the risk/benefit ratio favors extreme measures."

Conditions that may justify nerve destruction can include facet mediated pain (724.8, Other symptoms referable to back), certain types of degenerative disc disease (from the 722.xx series for Intervertebral disc disorders) and small herniated disc (such as spondylosis [721.3] or postlaminectomy syndrome [722.83] without radicular component or pain).

These cases often require additional documentation of failed treatments to help justify the denervation. Example: The patient must have had a previous facet block that proved pain was generated from that level to meet the medical-necessity guidelines for radiofrequency

Local blocks such as steroid injections often need pre-approval and authorization, depending on the carrier. Always check the carrier's guidelines before scheduling and completing the procedure.

2. Choose the Right Family

Your second step toward success is to locate the correct group of codes for the procedure. CPT includes several pages of nerve block and destruction codes, but paying close attention to section heads will lead you in the right direction. Block and destruction codes fall into four groups:

Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic, somatic nerves - codes 64400-64484

Introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic, sympathetic nerves - codes 64505-64530

Destruction by neurolytic agent (e.g., chemical, thermal, electrical, radiofrequency), somatic nerves - codes 64600-64640

Destruction by neurolytic agent (e.g., chemical, thermal, electrical, radiofrequency), sympathetic nerves - codes 64680-64681.

Tip: These groups list codes by treatment location, so be sure you report the correct area. Some locations include primary and add-on codes for multiple injections during the same session, so watch for that as well.

Specific procedure codes you'll find yourself repeatedly relying on include:

Epidural single injection code 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]). ESIs are often used for sciatica, spinal stenosis and other forms of back pain. They are some of the most common pain-management procedures and are often administered in a series of two-five blocks.

Catheter placement code 62350 (Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy). Catheter techniques are designed for inpatients. Groudine's group uses these for postoperative pain control or for pain that is intense but of limited duration. "Code 62350 is used when the pain control must be longer than several days," he says. "Implanting the catheter allows you to keep it in place for months or years. These are most often used for severe pain from failed back or cancer pain."

Continuous infusion code 64449 (Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration). Remember, this code includes daily management and has a 10-day global period, Johnson says. Don't charge extra for follow-up management days when you've already reported 64449.

Facet injection codes 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) and +64476 (... lumbar or sacral, each additional level [list separately in addition to code for primary procedure])

Transforaminal epidural codes 64483 (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level) and +64484 (...lumbar or sacral, each additional level [list separately in addition to code for primary procedure])

Paravertebral injection code 64520 (Injection, anesthetic agent; lumbar or thoracic [paravertebral sympathetic])

Neurolytic destruction codes 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) and +64623 (... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]).

3. Pay Attention to Agents and Techniques

Your next clue for correct coding lies with the injection agent and technique. You can often bill separately for the drug, depending on the procedure, says Tonia Raley, CPC, claims processing manager for Medical Information Solutions in Phoenix.

Nerve block drugs can include anesthetics, antispasmodics, opioids or steroids/anti-inflammatories. The medication used depends on the physician's preference, patient diagnosis, the patient's past response to medications, and other factors. Physicians commonly use:

Bupivacaine/Marcaine - S0020 (Injection, bupivacaine HCl, 30 ml)

Depomedrol - J1020, J1030 and J1040 (various dosages of Injection, methylprednisolone acetate)

Kenalog - J3301 (Injection, triamcinolone acetonide, per 10 mg).

You will probably report J3490 (Unclassified drugs) for drugs not listed in HCPCS. Remember: The Depomedrol (used for lumbar epidural steroid injection, or LESI) should be preservative-free.

The physician can choose from a variety of techniques for nerve destruction: chemical (injecting alcohol), thermal (using heat), electrical (using electrical stimulation) or radiofrequency (using heat to lesion a nerve to relieve pain). Chart notes referencing any of these techniques indicate that the physician destroyed the nerve rather than simply deaden it for a period of time.

Each technique is better suited for particular situations, Raley says:

Chemical destruction is used most often for celiac plexus lesioning rather than actual blocks. Chemical destruction is better for treating areas with a lower risk of lesioning a motor nerve (such as in the pancreatic area).

Physicians often use thermal destruction techniques for IDET procedures (0062T, Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level; and +0063T ... one or more additional levels [list separately in addition to 0062T for primary procedure]).

General or neurosurgeons use electrical techniques more often than pain management specialists do.

Radiofrequency is similar to thermal destruction because both techniques involve heat application. Radiofrequency is a more precise lesioning technique because the physician can control the lesion point, which means physicians routinely rely on it. They sometimes use radiofrequency for IDET procedures, but they use it more often for facet joint denervation.

Bottom line: Whatever technique the physician uses, he should always completely document the procedure so you can code it accurately. Watch for details such as bilateral procedures so you can code each level correctly (appending modifier -50, Bilateral procedure, to differentiate the injections).