Anesthesia Coding Alert

Increasingly, commercial payers and some local Medicare carriers cover IntraDiscal ElectroThermal (IDET) therapy. Because guidelines are carrier-specific, individual payers should be asked before a procedure is performed if  it is covered and, if so, which codes are used.
 
The coding of IDET treatment of disc-related lower back pain has been controversial since the technique received FDA clearance in 1998. Although the number of commercial carriers that pay for IDET is increasing, many still do not cover the treatment. Some local Medicare carriers also do not cover the technique, which they consider investigational.
 
IDET has other reimbursement issues. No CPT code describes the procedure, which further complicates coding and billing.
 
IDET is a form of intradiscal heating that involves positioning a catheter with a resistive coil at its tip that generates heat. (Another method uses a needle to deliver radiofrequency-generated heat.) In both methods, the controlled heat causes cauterization of granulation tissue, the shrinking of collagen fibers and thermocoagulation of nervous tissue. It is used in the treatment of discogenic pain that is not successfully treated with the more traditional approaches of medications, injections and physical therapy. 
 
Many pain physicians and a growing number of carriers consider the noninvasive service to be a cheaper and safer alternative to spinal fusion for some patients, particularly those with chronic lower back pain and with annular disruption in one or more discs.

 
Although good treatment outcomes have been reported, many carriers do not cover IDET treatments. Some Medicare carriers (i.e., Florida Medicare) clearly state in their LMRPs that IDET procedures are not covered because they are considered investigational.
 
This is true for some commercial carriers, such as Aetna U.S. Healthcare, which lists IDET among its non-covered services. Aetna's published policy on IDET states: "In the early stages of investigation, [IDET] appears promising; however, further study is warranted to compare efficacy against other intradiscal heating procedures, to determine the precise pathology most successfully treated by the procedure, and to assess the long-term outcomes of this procedure as compared to other more conventional therapies."
 
Meanwhile, even among payers who reimburse IDET treatment, the means by which they do so may vary greatly, in part because there is no CPT code for the treatment and in part because such cases are reviewed on a case-by-case basis.
 
Some of the Medicare carriers willing to pay for IDET for some patients want unlisted-procedure code 64999 (unlisted procedure, nervous system) used. This code is also recommended by the AMA and by most coding specialists, including Amy Mowles, a nationally recognized speaker on pain management and CEO of Mowles Medical Practice Management in Bowie, Md.
 
"Procedure notes need to be attached to the claim because it is an unlisted code," Mowles says. Because the claim has to be reviewed manually, she cautions, "not only does using 64999 not guarantee payment, it is a guarantee that the payment process will be slowed down."
 
The same applies to 22899 (unlisted procedure, spine), which HGSA (formerly Xact), the Medicare Part B carrier in Pennsylvania, and some other carriers instruct their physicians to use rather than 64999.
 
Some private carriers, meanwhile, may prefer that S codes be used to report IDET treatments. S codes are temporary HCPCS codes "developed by Blue Cross/Blue Shield and other commercial payers to report drugs, services and supplies. They may not be used to bill services paid under any Medicare payment system," according to HCPCS 2001, Medicare's Level II codebook.
   
HCPCS includes the following S codes:
 

S2370 -- intradiscal electrothermal therapy, single interspace
 

S2371 -- each additional interspace (list separately in addition to code for primary procedure).
 
    
Like the unlisted-procedure codes, an S code claim should be accompanied by detailed documentation, including a note or letter that clearly and accurately describes what the physician did.

 
Reporting treatments based on new technology such as IDET must often be approached on a carrier-by-carrier basis, because policies differ and cases are often assessed individually. As a result, the best payment strategy is to ask the carrier how the claim should be billed while obtaining preauthorization of coverage.
 
Oratec Inc., which manufactures SpineCATH, the only IDET product now on the market, instructs physicians that "local payers may have their own coding requirements. Before filing any claims, providers should verify these coding requirements in writing with local payers."
 
Oratec does not recommend a specific coding strategy, says Kent Hendrix, Oratec's manager of payer operations. However, the company has issued a list of "suggested" ICD-9, CPT and HCPCS codes that individual carriers may prefer.
 
Hendrix says the company suggests reporting the unlisted-procedure codes and S codes first. However, he says, some carriers may not be able to process these codes and will automatically reject them when they are filed. In such cases, Hendrix says, CPT codes may be required, depending on the carrier's claim-adjudication system.
 
Oratec lists four suggested codes:
 

62287 -- aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar (e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy)
 

64640 -- destruction by neurolytic agent; other peripheral nerve or branch
 

76005 -- 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
 

72295 -- diskography, lumbar, radiological supervision and interpretation.

     
There has been much controversy over the use of these codes for IDET treatments. The pain coding specialists contacted for this article agreed that these codes (or any other CPT codes) are inappropriate and should not be used for IDET treatments because they do not accurately describe the procedure performed. The exception is if the carrier specifically instructions you to do so in writing.
 
Hendrix says some carriers that pay for the procedure prefer these codes because they cannot process S codes or unlisted-procedure codes.
 
Upon physician request, Hendrix says, Oratec provides carriers that are reviewing IDET treatment with clinical information and meta- and cost analyses. At the same time, Oratec also submits its list of suggested codes to the carrier, which includes the four codes listed above as well as the unlisted-procedure codes and S codes mentioned earlier.
 
Some carriers have informed Oratec that they require the listed CPT codes because these codes have RVUs (unlisted-procedure codes and S codes do not) and they come closest to describing what the physician did.
 
The carrier may not relay this information to the physician, however, because "It's the physician, not we or the carrier, who ultimately selects the code that best describes what was done," Hendrix says.
 
Physicians must obtain the instructions to use 62287, 64640 or any other codes in writing because these codes may be considered inappropriate or even fraudulent in a future audit.
 
"Code 62287 describes the excision of a disc, which does not occur here. IDET does not remove a disk, it melts it. Therefore, using the code may be considered abuse or fraud," says Susan Callaway, CPC, CCS-P, a coding and reimbursement specialist and educator in North Augusta, S.C. Callaway stresses that if the carrier specifically instructs physicians to use these or any other CPT codes, the instructions must be obtained in writing.
 
One way to obtain the correct codes from a carrier in advance, Callaway says, is to submit a sample operative note and ask the carrier to preauthorize in writing not only the procedure but also the codes that are required.
 
The good news, Mowles says, is that "more and more private carriers, especially workers' compensation carriers, are covering the procedure on a case-by-case basis, so if you submit a clear and accurate operative report that describes why the procedure was necessary and what the physician did, there is a better chance you'll get paid." Mowles also urges physicians to ask for a face-to-face meeting with the medical director of a carrier that doesn't cover the procedure. "IDET can save carriers the cost of much more expensive spinal fusion surgery. Once the medical director understands the potential health benefits, the policy can change," she says.