Anesthesia Coding Alert

Most coders err with 64470, 64475 -- here's how to avoid becoming a statistic.

The Office of the Inspector General (OIG) recently released a report that should have you double-checking your claims for pain management facet joint injections. The OIG's Sept. 17 report reveals that 63 percent of "facet joint injection services allowed by Medicare in 2006 did not meet Medicare program requirements, resulting in approximately $96 million in improper payments for physician services." Steer clear of this coding pitfall with these tips.

Beware Physician's Office-Based Errors

The OIG report, "Medicare Payments for Facet Joint Injection Services," shows that 71 percent of facet joint injections performed in physicians' offices contained errors. On the other hand, only 51 percent of facility-based facet joint injections showed errors.

What OIG notes: The OIG report indicates that more than 60 percent of the errors found were "instances in which the physician billed incorrectly for bilateral facet joint injections."

For example: Physicians reported add-on codes to indicate that they injected a contralateral (opposite) side of a spinal level, although they should have simply appended modifier 50 (Bilateral procedure) to the facet joint injection code.

All these errors put your pain management practice under the OIG microscope. Here's how to dissect facet joint injections correctly and avoid the OIG's wrath.

First: Add-Ons Apply to Extra Levels

When reporting facet joint injections, you should choose either 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) or 64475 ( ... lumbar or sacral, single level), depending on the spinal area your pain management specialist treats.

For each additional level your specialist injects in the cervical or thoracic area, report +64472 ( ... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]).
For each additional level he injects in the lumbar or sacral area, turn instead to +64476 ( ... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]).

Second: Clarify Terminology

Although the descriptors for 64470 through +64476 specify spinal levels, your physician actually targets facet joint injection procedures at the space between vertebrae (in other words, the interspace), says Alexandra Cortina with Pain Billing Pros in Clearwater, Fla.

For instance: If your pain management specialist documents "facet joint injection at C4-C5," this represents a single injection to the joint between the fourth and fifth cervical vertebrae. However, your specialist can alternately perform injections of the two paravertebral facet joint nerves (medial branches) that provide sensory information from the single facet joint back to the spinal cord. In this situation, your specialist performs a total of two injections -- the first at the C4 vertebrae for the C4 medial branch, and the second at the C5 vertebrae to block the C5 medial branch.

According to a September 2004 CPT Assistant article, you should consider these two injections a single level. Regardless of whether your pain management specialist performs a single intra-articular facet joint injection or blocks both paravertebral facet joint nerves for that facet joint, report only one CPT code for the single level.

Third: Keep Modifier 50 at Hand

If your physician performs facet joint injections at the right and left side of the same spinal level -- for example, the right C5-C6 and left C5-C6 -- you should report only a single unit of service with modifier 50 appended for bilateral injections. Just be careful you don't exceed your carrier's utilization guidelines, says Heather Corcoran with CGH Billing in Louisville, Ky.

Watch out: You should not report bilateral facet joint injections as one unit of the first or single level code, and one unit of the add-on code for "each additional level." This would incorrectly report the pain management specialist's bilateral facet joint injections.

Errors happen both ways: You should take careful note that the OIG report also showed 29 underpaid services during the audit. And 100 percent of the undercoded services were instances when the physician billed for unilateral services when he actually performed bilateral injections. That resulted in a 50 percent underpayment, the report said -- and those are funds that should be flowing to the practice.

For example: Your pain management specialist injects intra-articularly or directly into the joint at the right and left C4-C5 and C5-C6 facet joints. You should report 64470-50 (for the initial bilateral injection at C4-C5) and +64472-50 (for the additional bilateral injection at C5-C6).

Bottom line: The OIG's findings emphasize the importance of thorough documentation and correct coding when it comes to bilateral injections. Stay sharp on your injection coding, and you'll stay on OIG's good side.

Editor's note: To read the complete OIG report, visit http://oig.hhs.gov/oei/reports/oei-05-07-00200.pdf.