Anesthesia Coding Alert

The next time you code an epidural steroid injection (ESI), take a closer look at your claim. You could be losing up to $86 if you miss an opportunity to report fluoroscopy code 77003.

Use this comprehensive look at coding pain management ESI encounters to be sure you're getting every dime you deserve.

The physician likely will choose an interlaminar epidural approach, placing the medicine inside the epidural space. "As long as the needle is positioned in the epidural or subarachnoid space with the needle [inserted] 'straight' in between the lamina," then the following are the correct codes, says Julee Shiley, CPC, CCS-P, CMC, in Raleigh, N.C.:

• 62310 -- Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

• 62311 -- ...lumbar, sacral (caudal).

Pay attention: Be careful not to confuse single injection codes 62310-62311 with the following continuous infusion or intermittent bolus codes:

• 62318 -- Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

• 62319 -- ... lumbar, sacral (caudal).

If the physician inserts the needle at an angle into the intervertebral foramen to perform an injection at the nerve root area this is a transforaminal (through the foramen) epidural injection.

With this type of epidural, the physician injects the medication into the lateral epidural space "bathing" a specific spinal nerve as it exits the spinal cord. For this approach, you'd use a different set of codes, as follows:

• 64479 -- Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level

• +64480 -- ... cervical or thoracic, each additional level (list separately in addition to code for primary procedure)

• 64483 -- ... lumbar or sacral, single level

• +64484 -- ... lumbar or sacral, each additional level (list separately in addition to code for primary procedure).

Add-on rules: You should report 64479 and 64483 as the primary codes for the first transforaminal injection to the cervical/thoracic or lumbar/sacral levels, respectively. Use add-on codes 64480 and 64484 for each additional injection at the cervical/thoracic or lumbar/sacral levels, respectively.

Example: The physician administers transforaminal ESIs at the right L4-L5 and L5-S1 intervertebral spaces, two different levels. You should report 64483 for the first lumbar injection and 64484 for the additional level injection.

Increasingly, physicians are using imaging guidance to verify precise needle placement for the ESI. You may report fluoroscopic guidance separately with 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).

The 2008 Medicare physician fee schedule lists an allowable reimbursement range of approximately $50 to $86 for 77003 (global service), depending on where your office is geographically located.

Watch for: The physician needs to include documentation that he used fluoroscopic guidance for the procedure, says Stacy Gregory, RCC, CPC, owner of Gregory Medical Consulting Services in Tacoma, Wash.
Don't get confused: The parenthetical note following 77003 states that codes such as 62310-62319 include "injection of contrast during fluoroscopic guidance and localization." This means that a provider cannot separately bill for the injection of contrast if performed during fluoroscopic guidance, but the note does not restrict a provider from reporting 77003 with these epidural injection codes.

Matching your ESI and fluoro codes to the proper ICD-9 code is essential for proving medical necessity. Many payers, including most Medicare carriers and some commercial payers, have coverage policies that spell out the diagnoses that indicate ESI medical necessity.

Example: Aetna states that providers should administer therapeutic selective transforaminal epidural injections as part of a comprehensive pain management program. Administration of more than three such injections per six months is subject to medical necessity review. They are generally medically necessary when used for "identifying the etiology of pain in persons with symptoms suggestive of chronic radiculopathy, where the diagnosis remains uncertain after standard evaluation (neurologic examination, radiological and neurodiagnostic studies)" (http://www.aetna.com/cpb/medical/data/700_799/0722.html).

The following list shows some of the conditions and corresponding ICD-9 codes indicated to support medical necessity for epidural injections by many payer policies:

• 722.0-722.2 -- Displacement of intervertebral disc without myelopathy...

• 722.4-722.6 -- Degeneration of intervertebral disc...

• 722.8X -- Postlaminectomy syndrome...

• 723.0, 724.0X -- Spinal stenosis...

• 723.4, 724.4 -- Neuritis or radiculitis...

Remember: You must base your ICD-9 code on the documentation. You should never choose a code based solely on what the payer covers.

In addition to the procedure and diagnosis, you may report the steroid used if your practice bears the cost for an ESI, such as when you perform it in the physician's office.

Drugs the physician may use in an office setting include the following, says Eman Danial, CPC of Westgate Pain Management Group in Cleveland, Ohio:

• Versed, J2250 (Injection, midazolam HCl, per 1 mg) for moderate/conscious sedation

• Depo-Medrol, J1020 (Injection, methylprednisolone acetate, 20 mg) or J1030 (Injection, methylprednisolone acetate, 40 mg)

• Cortimed/Depo-Medrol, J1040 (Injection, methylprednisolone acetate, 80 mg)

• Marcaine (Bupivacaine) or Sodium Bicarbonate, J3490 (Unclassified drugs) -- Medicare does not cover these, but other payers may.

If you perform the procedure in an ASC or outpatient hospital facility, the facility provides the medications ,and you should not include them in the physician's billing, Danial adds.

Now that you've read about ESI CPT, ICD-9 and HCPCS coding, decide how you would code the following ESI scenario, and then check your answer below.

Example: In the office, your physician administers an L3-4 interlaminar lumbar ESI for a patient with a herniated lumbar disc. He uses fluoroscopy to guide needle placement. The drug injected is 40 mg of Depo-Medrol.

Solution: You should report the single lumbar interlaminar injection with 62311 and the fluoroscopy with 77003. Report the Depo-Medrol with J1030. For the diagnosis, you should report 722.10 (Displacement of lumbar intervertebral disc without myelopathy).