Anesthesia Coding Alert

Trigger point, facet joint and epidural injections are the "meat and potatoes" of pain management practices. All three of these important treatments have new reimbursement levels beginning this month, when the new conversion factors and Medicare fee schedules for 2003 go into effect.

Payers base reimbursement on where the physician performs the service as well as the procedure itself. So your first step is to correctly code the place of service. Services provided in a hospital, a skilled nursing facility, or an outpatient care center are considered "facility" services. Those provided in a physician office, patient home, or similar environment are "nonfacility" services.

Reimbursement for nonfacility services is traditionally higher than for facility services to help offset extra expenses the provider incurs (such as equipment, medications, nursing and other technical personnel services, etc.). But unfortunately for providers, reimbursement for some of the most common pain management procedures decreases this year. Some of these cuts are partially offset by increased reimbursement for related procedures, but the overall trend is downward.

For example, the nonfacility total payment for 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) in 2002 was $216.83. The same procedure's reimbursement in 2003 increases to $240.76 (based on the national conversion factors of $36.1992 for 2002 and $34.5920 for 2003). That's a plus for providers, but reimbursement for each additional injection (+64472, ... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) drops from $191.13 to $116.58.

Changes in facility reimbursement for these two injection codes aren't as dramatic, but they still decrease. Single-level reimbursement drops from $88.69 in 2002 to $87.86. Additional-level reimbursement declines from $61.90 to $58.81.

Several other injections follow the same reimbursement pattern nonfacility fees for single injections increase in 2003, but fees for additional levels drop.

Many coders and practitioners feel that this is Medicare's way of trying to make physicians feel they're getting something when really they're not. Reimbursement for the initial level (injection) goes up slightly, but reimbursement for the additional level(s) decreases. The only way a physician comes out ahead is if he only performs one level, which is rare. But coders acknowledge that it could have been worse reimbursement for both codes could have dropped instead of for just one.

Another big reimbursement change applies to 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid). The nonfacility fee jumps from $374.30 to $406.80 (although facility fees decrease from $66.24 to $62.96). According to the note beneath the descriptor, you should report 27096 only when the physician uses radiological guidance for the procedure (the note states, "27096 is to be used only with imaging confirmation of intra-articular needle positioning").

Some practices might not have picked up on this note when it was added to CPT2002, says Carla Thibodeaux, CPC, owner of the anesthesia and pain management consulting firm Excel Practice Management in San Antonio.      

"Some physicians tend to use 27096 for any sacroiliac (SI) injection, but you shouldn't if radiological guidance isn't used. In that case, you code with 20610* (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa])."                                                            

A second note beneath code 27096 instructs you to report supervision and interpretation with 73542 (Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation). These must be formal arthrography and radiological reports, and CPT considers fluoroscopic guidance (76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) as part of the more comprehensive 73542, says Tonia Raley, CPC, claims processing manager with Medical Information Management Solutions in Phoenix. Code 76005 does apply if the physician uses fluoroscopic guidance without a formal arthrography.        

"Basically, you have two choices," Raley says. "You can code for an SI injection with fluoroscopy, or you can code for the injection with a full report."                                     

Another important fact to remember is that Medicare will deny 27096 if the physician performs it alone.

Some Changes May Help in the Long Run

Fees for trigger point injections have decreased as well, but changes to the code descriptors in CPT2003 might be advantageous to providers. The affected codes are 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). Until CPT2003, these codes represented muscle groups, not individual muscles. Although CMS reduced reimbursement for 20552 and 20553 for facility and non-facility services, the terminology change could increase overall reimbursement. (See "Count the Muscles for New TPI Coding" on page 4 for examples related to these codes.)               

 One thing to remember when billing TPIs is that Medicare will only cover them based on medical necessity, Raley says. "Medicare will only pay for three diagnosis codes for TPI," she says. "These are 729.0 (Rheumatism, unspecified and fibrositis), 729.1 (Myalgia and myositis, unspecified) and 729.4 (Fasciitis, unspecified)."                                                                                        

 Medicare carriers will deny claims submitted with any other diagnosis codes. Ensure that your diagnosis codes are linked properly to the procedure(s) and that the physician's documentation supports the diagnosis to avoid denials.

Thorough documentation of the injections is vital, Thibodeaux adds. "Many physicians just say they performed 'multiple'injections, so you might not have a clear picture of what was done," she says. "You want to code procedures as bilateral (by appending modifier -50 [Bilateral procedure] or -RT or -LT to identify which side of the body was treated) when it's appropriate, but you can't do that unless it's specified in the chart. Teach your physicians to indicate when procedures are bilateral so you can code them accurately and get appropriate reimbursement.                                                                                         

"Note: The fees discussed here are based on the national average conversion factors, but actual factors in many states are higher or lower, depending on a variety of criteria. Like any information related to fee schedules and reimbursement, check with your local carriers for specific guidelines in your area.