Anesthesia Coding Alert

Follow these tips to make refiling bilateral claims easy

Last fall, Medicare shocked coders by publishing its Physician Fee Schedule with surgical indicator "0" for some codes for popular procedures -- including transforaminal add-on codes. Now that Medicare has reversed its decision, be sure you're filing claims correctly and getting reimbursed for past claims.

2005 Fee Schedule Threw Coders a Curveball  

Medicare's physician fee schedule published in October 2005 assigned bilateral surgical indicator "0" to transforaminal add-on codes +64480 (Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) and +64484 (... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]).
 
That meant Medicare no longer accepted modifier 50 (Bilateral procedure) for 64480 and 64484, no matter how many injections your provider administered. That was a big hit to groups' bottom lines because the bilateral payment adjustment rule (which allows 150 percent payment adjustments for bilateral procedures) couldn't come into play.
 
The announcement surprised coders everywhere, including Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. "I was astounded to say the least, as this change was absolutely contradictory to the CPT parenthetical note: 'Codes 64470-64484 are unilateral procedures. For bilateral procedures, use modifier 50,' " she says.
 
"Medicare goofed," adds Jann Leinhard, CPC, a New Jersey coding consultant. "There are two injection sites -- left and right. Some providers might use the same needle, but there are two separate, identifiable sites."

Medicare Reverses Its Stance

Medicare typically releases its physician fee schedule (MPFS) at the end of the year for the following year; Medicare then releases quarterly updates for changes and corrections to the existing schedule. The 2006 second- quarter update (transmittal 897, change request #4399) announced the error regarding bilateral indicators:
 
"Also, in the October 2005 update to the MPFSDB, the bilateral surgical indictors were inadvertently changed from '1' to '0' for CPT codes 63035, 63043, 63044, 64480 and 64484. This CR reinstates the bilateral surgical indicators for these codes to a '1' effective Jan. 1, 2006."
 
There's more: The announcement continues, "Your carrier will adjust their systems and the 2005 MPFSDB to reflect a multiple-procedure indicator of a '0' for CPT codes 20931, 20937, and 20938 ... and a bilateral surgery indicator of a '1' for CPT codes 63035, 63043, 63044, 64480 and 64484."

Indicators Drive Your Reimbursement

"The bilateral-surgery indicator in the MPFS defines procedures that may be submitted as 'bilateral' and how reimbursement for bilateral procedures is calculated," Hammer says. She offers information on reimbursement for these procedures in the table below, based on 2006 national Medicare allowed fees; the amounts in parenthesis represent the potential loss for processing claims with an incorrect bilateral indicator:

                                           Facility Service           Nonfacility Service

64479                               $121.69                       $372.53
64479-50                         $182.48 ($60.83)       $558.80 ($186.27)
64480                               $79.79                          $179.14
64480-50                         $119.94 ($39.98)        $268.71 ($89.57)
64483                               $113.31                        $395.78
64483-50                         $169.97 ($56.66)       $593.67 ($197.89)
64484                               $71.02                          $187.52
64484-50                         $106.53 ($35.51)        $281.28 ($93.76)

Check Your Transforaminal Guides 

Fortunately for providers, Medicare now says surgical indicator 1 does apply to 64480 and 64484. Verify that your system reflects the change, and prepare to refile claims to receive missed reimbursement.
 
Don't relinquish rightful pay: The announcement reinstated the bilateral indicator to 1 effective Jan. 1, 2006, but you can also resubmit incorrectly paid claims from Oct. 1 to Dec. 31, 2005. Medicare says that carriers are obligated to reimburse only the additional amount for claims brought to their attention. Although refiling claims can be aggravating, not going through the channels means your group is leaving money on the table.
 
"Transforaminal epidural injections are a very common pain management procedure that providers typically use to treat radiculopathy," Hammer says. Other common indications for transforaminal injections include:

 • radicular pain of postsurgical scarring (722.8x, Postlaminectomy syndrome)
 
 • monoradicular pain when the physician cannot find a surgically correctable lesion (such as 729.2, Neuralgia, neuritis, and radiculitis, unspecified; and other radicular pain diagnoses)
 
 • Radicular pain when urgent surgery is not indicated or contraindicated due to medical conditions.

Reporting modifier 50 comes into play when physicians treat patients for bilateral radicular pain for conditions such as spinal stenosis. Your diagnosis codes supporting treatment vary by region: 723.0 (Spinal stenosis in cervical region), 723.4 (Brachial neuritis or radiculitis NOS), 724.0x (Spinal stenosis, other than cervical) or 724.4 (Thoracic or lumbosacral neuritis or radiculitis, unspecified).