Anesthesia Coding Alert

CMS clarified its stance on correctly reporting modifier 50 (Bilateral procedure) and add-on codes for facet joint injection services with an effective date of Aug. 31, 2009 (CR Transmittal R526OTN). Here's the quick version of what you need to know:

• If your physician performs facet joint injections on both sides of one level of the spine (such as right C4-C5 and left C4C5), you must append modifier 50 with the appropriate procedure code.

• If your physician performs facet joint injections on multiple levels on the same side of the spine (such as right C4-C5 and right C5-C6), submit the appropriate CPT addon code to report the additional levels -- not modifier 50.

When it's time to report facet joint injections, you have four coding choices:

• 64470 -- Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level

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

• 64475 -- ... lumbar or sacral, single level

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

Use 64470 and 64475 for single injections to the cervical/thoracic or lumbar/sacral area. Add +64472 or +64476 for additional injections to the same side of the spine. When the procedure is bilateral, append modifier 50 to the corresponding facet joint injection code.

"The issue wouldn't be too complex if there was only the single code for all levels, but the add-on code really seems to throw providers and coders for a loop," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver.

The transmittal clarifies that you must report modifier 50 when the right and left facet injections are administered at the same level.

"If you do a right facet injection you can't do the left from the same injection," explains Scott Groudine, MD, professor of anesthesiology at Albany Medical Center in New York. "You have to start over again, so the work is very similar to doing another level on the same side." Because the work is essentially the same (no difference for a different level versus the contralateral side), many physicians thought it appropriate to be paid for a new level.

Reimbursement watch: Multiple procedure discounts don't apply to add-on codes, so you'll be paid the full amount if your physician bills +64472 or +64476. If you append modifier 50 to indicate a bilateral procedure, however, expect a 50 percent reduction in allowable.

Learn more: The revision stemmed from an OIG medical record review of facet joint injection services that showed physicians incorrectly billed additional add-on codes to represent bilateral injections, with some specialties having an error rate up to 97 percent. The data studied was from procedures performed in 2006. The complete OIG report is viewable at

 www.oig.hhs.gov/oei/reports/oei-05-07-00200.pdf.