Anesthesia Coding Alert

Take these 2 easy steps to ensure correct coding

You're stymied by a chart on your desk: A new physician in your pain management group uses EMG guidance for steroid injections into the piriformis muscle. Which way do you turn, considering that CPT includes only codes for EMG (electromyography) guidance associated with chemodenervation? The answer might lie in the medication or injection material, not the injection procedure itself. Here's how to find the correct answer every time.

Step 1: Consider EMG Options

CPT currently only includes EMG guidance codes for injection procedures 64612-64614 (Chemodenervation of muscle[s] ...), says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif. You report +95874 (Needle electromyography for guidance in conjunction with chemodenervation [list separately in addition to code for primary procedure]) for EMG guidance codes for those specific injections.

As a pain management coder, however, you'll find that those codes don't provide automatic answers for your situation.

Roadblock 1: The problem with reporting these chemodenervation codes is that your provider must inject botulinum toxin (Myobloc or Botox) during these procedures -- and that's not what medication your physician is injecting.

Roadblock 2: CPT includes other EMG codes in the Electromyography and Nerve Conduction Tests section (95860-95872), but you report these codes for diagnostic studies to evaluate the functional status of nerves and muscles -- not to report needle guidance. In addition, Chapter 2 of the Correct Coding Initiative (CCI) manual states that you must include a complete diagnostic report in the medical record before reporting 95860-95872. Because your pain management specialist is using EMG for needle guidance of a piriformis injection rather than as a mode of diagnostic testing, his documentation will not include the interpretation requirements needed for the other EMG codes -- which means you can't report them.

Step 2: Look Beyond the Procedure Itself

The term "chemodenervation" refers to botulinum toxin use to temporarily prevent a nerve from stimulating its target muscle, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. The problem, however, is that your physician isn't injecting botulinum toxin into the piriformis muscle; he's injecting a steroid instead.

What that means: Follow your provider's steroid injection procedure documentation. If he documents the injection of a palpable piriformis muscle trigger point, you might look to 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]). However, if the documentation lacks details regarding the presence or injection of the muscle trigger point, you should report 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) instead.

Extra FYI: The Medicare carrier Noridian recently advised providers that "when the injection focus is in the piriformis muscle or surrounding muscle groups, 64999 (Unlisted procedure, nervous system) should be used."

Complete the claim with diagnosis 355.0 (Lesion of sciatic nerve) for piriformis syndrome.

Diagnosis note: ICD-9 does not include a listing for "piriformis syndrome" in the alphabetic index. Instead, it lists the condition under "Syndrome" by the old English spelling (pyriformis), which directs you to 355.0.

Stimulator possibility: Some providers might use a peripheral nerve stimulator rather than EMG to verify needle placement for these types of injections. You should not separately report even this needle guidance approach, however. According to Chapter 11 of the CCI Manual, "electrical stimulation used to identify or locate nerves as part of a procedure involving treatment of a cranial nerve or peripheral nerve (e.g., nerve block, nerve destruction, neuroplasty, transaction, excision, repair, etc.) is part of the primary procedure."