Anesthesia Coding Alert

Tip: Yes, you can code separately for fluoro guidance.

Neurologists and pain management specialists frequently perform interlaminar epidural injections. The next time you're faced with one of these claims, be sure to mark the differences between interlaminar epidurals and other common spinal injections.

Skip the Bilateral Modifier

If your interventional physician performs more than one interlaminar epidural injection in the same spinal region, you don't automatically append modifiers.

Here's why: When your provider injects a substance into the epidural space via an interlaminar approach, the drug diffuses into the entire area. The spreading eliminates the need to inject medication into both sides of the space to achieve the desired results. Therefore, you won't need to include modifier 50 (Bilateral procedure) on your claim to document that the provider treated the complete space.

Watch Levels, Not Injections

By the same token, multiple attempts to reach the same epidural space don't equal multiple procedures. You learn this because of the procedure descriptor for interlaminar epidural injections:

• 62311 -- 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; lumbar, sacral (caudal).

Explanation: Code descriptions for interlaminar epidural injections do not include the term "level." The verbiage differs from transforaminal epidural injection code descriptions ("single level" or "each additional level"), because "level" refers to an individual vertebral segment. Code 62311 and related procedures (62310, 62318, and 62319) describe injections to an anatomic region (cervical, thoracic, lumbar, or sacral) rather than levels, or individual segments. Therefore, you only report 62311 once per date of service.

Caution: Verify that you and your payer speak the same language when discussing spinal levels. "One problem I've had when dealing with worker's compensation was the 'point of entry,'" says Eman Danial, CPC, office/billing manager for Westgate Pain Management Group in Cleveland, Ohio. For example, the physician might note that he injected the needle at L4 when the payer had preapproved the claim for an injection to L3. "If they denied the claim saying it wasn't the approved level, we had to clearly explain that the injection wasn't to treat that exact level, but was treating the whole region," Danial says.

Remember Separate Fluoro Is OK

Most physicians use fluoroscopic guidance to pinpoint the injection site and ensure they inject medication into the correct  location. If your physician uses fluoroscopy, add 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) to your claim.

Confusion: Some insurance companies deny 77003 with 62311, stating the procedure includes fluoroscopic guidance. "The description clearly does not include 'fluoroscopic guidance,' but does include the physician work of the actual injection of contrast during fluoroscopic guidance and localization," Danial says. "I think that's where the confusion comes from."

"It's the actual physician injection of contrast that you cannot separately report, not the radiologic service of using fluoroscopic guidance for needle placement," adds Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Interesting note: Correct Coding Initiative (CCI) edits do not bundle 77003 with the 6231x injection codes, giving you clearance to report the codes together. Assign the Correct Diagnosis

Many conditions can lead to a patient having interlaminar epidural injections, so be sure to choose the most accurate diagnosis. Common options include:

• Reflex sympathetic dystrophy/CRPS Type I (337.2x)
• Spondylosis without myelopathy (721.0, 721.2 " 721.3)
• Disc displacement (722.0 " 722.11, Displacement of intervertebral disc without myelopathy)
• Disc degeneration (722.4 " 722.5X)
• Post-laminectomy syndrome (722.8X)
• Radiculitis (724.3, 724.4)
• Spinal stenosis (723.0, 724.01-724.02).

Check with the individual payer's coverage policy for ICD- 9 codes that meet their medical necessity requirements. For example, many payers don't cover interlaminal epidural injections for spondylosis with myelopathy (721.41- 721.91, Thoracic or lumbar spondylosi with myelopathy).

Remember, however, to always report the patient's condition and the physician's diagnosis, despite your expectations of coverage.