Anesthesia Coding Alert

Focus on correct Dx, CCI edits to set your practice on the path to error-free claims.

You have a head start on understanding the ins and outs of transforaminal epidurals, and how to code them properly. But there's more to know about these procedures in order to capture your pain management provider's deserved reimbursement and keep the Office of Inspector General (OIG) from looking your way.

In last month's Anesthesia and Pain Management Coding Alert, you learned about transforaminal epidurals by determining what the procedure is, which four codes to pick from, the importance of levels, whether fluoroscopy enters the equation, and, finally, the crucial task of checking with your local carriers (see "Prepare for OIG Scrutiny of Transforaminal Epidurals in 5 Steps," Vol. 12, No. 1). Now take these last few steps to ensure you're coding right every time.

4. Match Dx for Medical Necessity

Many payers, including Medicare, have coverage policies that explain their approved diagnoses to support medical necessity for transforaminal epidural injections. Staying up to date on the latest policies is key to your reimbursement, especially with the OIG's increased interest.

Most payers look for information in the patient's medical record such as: Whether the test was for diagnostic or therapeutic reasons, Pre- and post- evaluation of the patient, The type of patient education given, and Subjective or objective response from the patient both pre- and post-procedure.

For diagnostic purposes a transforaminal epidural is usually justified by insurers under a number of different circumstances, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. These include when the epidural "differentiates the level of radicular nerve root pain, differentiates between radicular and non-radicular pain, evaluates discrepancies between imaging studies and the clinical picture, identifies the source of pain when multiple nerve roots are compressed, and evaluates the nerve root responsible for post surgery nerve pain," says Groudine.

In addition there are four commonly acceptable conditions for therapeutic indications:

1. Pain resistant to conservative treatment or when surgery is contraindicated.

2. Post-decompressive radiculitis or post-operative scarring.

3. Monoradicular pain confirmed by a diagnostic block in which a surgical lesion cannot be identified.

4. Treatment of acute herpes zoster or post herpetic neuralgia.

Example: A physician performs an L5-S1 transforaminal epidural steroid injection for persistent L5 radicular pain, secondary to post-surgical scarring. You would report 64483, (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level) and 722.83 (Postlaminectomy syndrome of lumbar region). This is also known as lumbar postlaminectomy syndrome, failed back syndrome, or failed management syndrome.

"Each insurance company may have its own list of covered diagnoses for these procedures, and they may or may not match your local Medicare LCD," says Dawn Shanahan, CPC, supervisor of coding for Florida Gulf to Bay Anesthesiology Associates in Tampa. "Be sure to check the payer's Web sites." ICD-9 codes that payers might consider acceptable for the injections include (but are not limited to):

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 ...

Caveat: Whatever your payer's coverage policy might state, always base your coding on the documentation. You should never choose a diagnosis code based solely on what the payer covers.

Remember: Each Medicare contractor can set their own diagnostic or therapeutic requirements. You might find variances or even occasional direct contradictions between some Medicare contractor coverage policies.

Check your payer's policies before billing.

5. Check the CCI Edits

Keeping up with the OIG Work Plan is important, but so is staying up to date on Correct Coding Initiative (CCI) edits.

Occasionally, pain management providers may find it necessary to perform an interlaminar epidural injection (such as 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) and also a transforaminal epidural injection in the same spinal region (such as 64479, Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level) during the same patient encounter, says Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Mo.

CCI edits consider these codes to be mutually exclusive to one another, which means these procedures typically cannot reasonably be performed at the same anatomic site or same patient  encounter. Mutually exclusive CCI edit pairs are based on the medically impossible/improbable likelihood that the two procedures could be performed at the same patient encounter. Multiple approaches to the same procedure are mutually exclusive of one another and should not be reported separately.

Beware: Some circumstances, however, might allow you to append a modifier to bypass the bundling edit and report both injection procedures, for example, when your provider administers the epidural injections at the different anatomic sites (such as a medically necessary interlaminar epidural at the C7-T1 spinal level and a transforaminal epidural at the T10-T11 spinal level). Because of the variation in payer bundling edits, always check how the guidelines apply to your case.

"I have yet to see these injections at the same level during the same encounter. However, if the injections were performed and justifiable, the provider should try to get paid for each because they involve different approaches and setups," Groudine adds.