Anesthesia Coding Alert

Verify that you're counting injections and levels correctly to keep claims clean.

The Office of Inspector General (OIG) Work Plan for 2010 includes a closer look at Medicare payments for transforaminal epidural injections. The Work Plan specifically states, "We will review Medicare claims to determine the appropriateness of Medicare Part B payments for transforaminal epidural injections."

Stay out of the OIG crosshairs by ensuring that your pain management specialist documents each procedure thoroughly. Follow these steps to count levels and assign the appropriate codes correctly.

1. Understand What ‘Transforaminal' Means

Physicians often administer transforaminal epidurals laterally through the selected neuroforamen under fluoroscopy, says Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Mo. Once there, the physician performs an injection at the nerve root area to help relieve the patient's pain. The medication goes into the anterior epidural space, "bathing" a specific spinal nerve as it exits the spinal cord.

CPT includes four codes to represent transforaminal epidural injections, which you choose between based on the injection site and number of injections:

• 64479 -- Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level (2009 national average Medicare reimbursement of $114.69 facility/ $253.55 non-facility)

• +64480 -- ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure) ($75.02 facility/$127.68 non-facility)

• 64483 -- ... lumbar or sacral, single level ($100.99 facility/$246.70 non-facility)

• +64484 -- ... lumbar or sacral, each additional level (List separately in addition to code for primary procedure) ($63.84 facility/$125.15 non-facility).

Procedure note: Although you report the same codes, a transforaminal injection is different from a selective nerve root block (SNRB). With SNRB, your provider injects right beside the nerve root where the nerve exits the foramen. The injection occurs outside the spine, which differs from a transforaminal. Coders sometimes interchange the terms, but knowing the difference in technique will help you better understand your physician's documentation.

2. Pay Attention When Counting Levels

Although the transforaminal injection descriptors specify spinal levels, your physician actually targets the space between vertebrae -- the interspace. This difference in code terminology and the procedure can confuse coders, so help your chances with the OIG by knowing how to count levels correctly. Remember you're counting interspaces, not vertebral bodies.

Tip: When the provider inserts the needle through the foramen into the interspace between discs (for example, at L4-L5), that is a spinal level you code with 64483. If your  provider inserts another needle into the next interspace (for example, at L5-S1), consider that a second spinal level and code report +64484 along with 64483.

Important: If your provider injects both sides of the same level, report a bilateral injection, not separate levels. "Even though payers require various claim formats, that doesn't mean that each side at the same spinal level is a different level," Mehmert explains.

Next step: Then check your payer's guidelines for bilateral reporting. "Most of the insurance companies I deal with state to use the 50 modifier (Bilateral procedure) and file on one line," says Dawn Shanahan, CPC, supervisor of coding for Florida Gulf to Bay Anesthesiology Associates in Tampa. In that case, code a bilateral transforaminal injection at L4-L5 as 64483-50 rather than 64483 with +64484.

Codes 64479-64484 have a bilateral surgery indicator of "1." They are considered unilateral procedures and most insurers will pay 150 percent for a bilateral block from this code family. When reporting a unilateral block with 64479-64484, include modifier LT (Left side) or RT (Right side) as appropriate so the payer fully understands the procedure.

3. Verify Whether Fluoroscopy Code Applies

"Although CPT does not specifically state that fluoroscopy must used to report these codes, it's almost a universal industry standard to use fluoro," Mehmert says. When your physician uses fluoroscopic guidance report 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) in addition to the procedure code.

"There needs to be a mention of the fluoroscopy in the documentation as well as a hard copy of the film in the patient's medical record," Shanahan says. "My physician mentions the use of fluoro as well as the type and amount of dye used or if the dye was not used and why."

Watch guides: Know your payers, because insurance companies have different guidelines for how many levels can be injected during the same encounter, the time between procedures, and other parameters. "For example, Blue Cross/Blue Shield of Florida presently states that a patient can receive diagnostic injections no sooner than every week, whereas the therapeutic injection time is no sooner than eight weeks," Shanahan says.

Other payers, however, have policies that deny treatment as not reasonable or medically necessary when your physician administers combinations of epidural, facet, lumbar sympathetic, or bilateral sacroiliac joint blocks on the same day.

CPT includes many parenthetical notes explaining when you can -- or cannot -- report 77003 with various injection procedures. None of the notes, however, restrict you from submitting 77003 with transforaminal epidural codes 64479-64484. Because your physician needs to use luoroscopy or a CT scan to confirm needle placement in the transforaminal epidural space, you might raise payer eyebrows if you don't report 77003 with the injection codes.

Coming next month: Two more ways to keep your transforaminal claims off the OIG radar.