Anesthesia Coding Alert

Question: A patient came to the office for treatment of L3 radiculitis and ankylosis. The pain management specialist administered a transforaminal epidural steroid injection and an SI joint injection during the same session because the patient is on long-term anticoagulants and would be at risk for DVT if the anticoagulants had to be repeatedly stopped and restarted. He used epidurography to confirm epidural spreading and fluoroscopic guidance to assist with the joint injection. The payer denied our claim without explanation. How should we code the encounter? 

New Jersey Subscriber

Answer: You need to evaluate whether any procedures your specialist performed are components of other procedures, especially when reporting several codes for a single encounter. First, consider the applicable codes:

• 64483 -- Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
• 27096 -- Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
• 77003 -- Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction.

Next, check for overlapping components. The current Correct Coding Initiative (CCI) edits bundle the transforaminal epidural injection code (64483) into the SI joint injection (27096). You can, however, bypass the bundle with a modifier when appropriate. Reporting a modifier to unbundle the edit is appropriate in this case because your provider did not use the transforaminal epidural steroid injection as a mode of anesthesia for the SI joint injection. You'll choose modifier 59 (Distinct procedural service). Edits also bundle fluoroscopy code 77003 as a component of 64483, but you can bypass the edit based on the provider using fluoroscopic needle guidance for a separate and distinct procedure (the SI joint injection).

Your coding should be as follows:

• 64483 with modifier 59 and linked to diagnosis 724.4 (Thoracic or lumbosacral neuritis or radiculitis unspecified)
• 27096 linked to 724.6 (Disorders of sacrum)
• 77003 with modifier 59, linked to 724.6

Note: You'll also want to note diagnosis V58.61 (Long-term [current] use of anticoagulants) to justify administering both injections during the same encounter. You might also need to append modifier 26 (Professional component) to 77003 if the specialist performed the procedures in a facility site of service rather than a physician's office.