Anesthesia Coding Alert

Watch injection number and frequency: They're more important than you think

You've selected the correct code for a facet injection procedure based on the injection location and whether you're reporting a first-level or additional injection. But don't stop there " true success also depends on the number of injections and frequency.

Success Hinges on Numbers and Frequency

When you code a facet injection, you should select from four 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).
 
Determining the injection location should be simple because of the procedure notes. Teaching physicians how to communicate the appropriate number of injection levels is a common problem, says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C. But an even bigger issue " and the primary reason carriers deny facet claims " is injection frequency, she and Myriam Nieves, CPC, ACS-PM, owner of Precision Medical Systems in Ft. Lauderdale, Fla., agree.
 
"Many carriers only pay for three injections per level every six months," Bukauskas-Vollmer says. "They also have guidelines for how many levels they'll reimburse for each session. Many carriers will pay for three injections but want notes if the physician administers a fourth injection."
 
Carrier requirements for facet injection levels vary as much as acceptable diagnoses. For example:
 
• Palmetto GBA in North Carolina does not make any reference in its policies to the frequency of facet injections they will reimburse.
 
• Palmetto GBA in Ohio and West Virginia, by contrast, will not reimburse more than three levels at a time, whether the physician administers unilateral or bilateral injections.
 
• Empire Medicare in New York approves a maximum of eight injections every 180 days.
 
• Noridian Administrative Services in Utah has even more restrictions: It only reimburses eight facet injections per year and requires written documentation after the first four.

"Being aware of your carrier's utilization guidelines can save your practice thousands of dollars," Nieves says.
 
Where you save: If you're not aware of carrier policies, you might administer injections that the carrier will refuse to reimburse because of medical necessity or other reasons. But if you inform the patient beforehand that the carrier does not believe the treatment is medically necessary, he has the right to receive the treatment but should know he will be financially responsible for it.

Follow Policies for Bilateral Reporting

Your key to successful reimbursement for bilateral facet injections is to learn how each carrier wants the procedure billed, Nieves says.
 
Example: Florida's Medicare, United Healthcare and state Department of Labor carriers want you to report bilateral injections on one line with modifier 50 (Bilateral procedure). Other carriers will accept injections reported on separate lines, with modifier 50 appended on the second line.
 
Your carrier's LCD (local coverage determination) should clearly outline how to correctly report bilateral injections.
 
Example: New York Empire's policy states, "If a particular level is injected bilaterally, the correct number of services remains as one, since only one level was injected. It would be appropriate to use the 50 modifier in the instance that a level was injected bilaterally. For example, if three lumbar facet joints were injected bilaterally, the correct coding would be one service of 64475-50 and two services of 64476-50."
 
Fee reminder: If you bill bilateral facet injections on a single line with modifier 50, remember to double your charge. For example, a physician who charges $400 for 64475 and $200 for 64476 when performing bilateral injections on two levels would report the procedure as:
 
64475-50 $800
 
64476-50 $400. 
 
"This is one of the most common mistakes with facet injection coding, although billing software can be programmed to automatically double the charge," Nieves says. "Keeping a spreadsheet of how each insurance company wants the bilateral procedures billed can help a great deal and will help keep your practice from raising red flags with carriers."