Anesthesia Coding Alert

Question: Our physician performs medial branch blocks and transforaminal injections in our office. Can we bill for IV sedation when he documents “local with IV sedation”?

Nebraska Subscriber

Answer: The correct answer depends on the payer’s stance. Many payers, including most Medicare carriers, bundle the sedation code in with the spinal injection code (such as 64479, Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level). If your payer follows that guideline, you should bill only for the transforaminal injection.

Silver lining: Even if you can only report one code, you should still bill for the medication used for the IV sedation, provided the physician has an invoice to show that he or she paid for the drug.