Anesthesia Coding Alert

CPT Codes 2000 deleted two codes (64442 and 64443) for facet joint injections and replaced them with four new codes (64470-64476) as well as a new fluoroscopy code. Last year, the Centers for Medicare & Medicaid Services (CMS, formerly HCFA) also revised its regulations to permit billing for bilateral injections.
     
Although many of these changes were welcomed by pain management physicians and their coders, they have been the source of much confusion, in part because not all carriers have published new local medical review policies (LMRPs) that reflect the changes. Many LMRPs, even those that have been revised, include complicated guidelines that govern how and when such injections may be billed.

Diagnostic and Therapeutic Injections

 
The term "facet joint injection" describes two distinct, although related, procedures. The first, sometimes referred to as an intra-articular block, involves the injection of anesthetic and/or steroid to denervate temporarily the paravertebral facet joint, which Coders' Desk Reference defines as "the bony surfaces between which vertebrae articulate with each other." In the second procedure, the injection is made into the facet joint nerve, often referred to as the median branch nerve. Both injections require fluoroscopic guidance.
 
Facet joint and median branch nerve injections are performed for two reasons. The first -- and, according to many LMRPs, the most important -- is as a diagnostic tool. The injections are used to document or confirm suspicions of posterior elemental biomechanical back pain by helping to determine whether a joint has structural abnormalities. Once the pain has been blocked, the patient may be asked to perform the same activities that usually aggravate the pain, and record any effects. The absence of lower back pain after the injections suggests that the facet joints are the source of the symptoms.
 
The injections may also be used therapeutically to provide temporary pain relief that may facilitate other types of treatment, such as physical therapy. Usually, these injections are given only to patients whose back pain is neither disc-related nor radicular (i.e., related to nerve roots).

Coding the Procedures

 
CPT includes the following four codes to report facet joint injections:
 

64470 -- injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level
  

64472 --  ... cervical or thoracic, each additional level (list separately in addition to code for primary procedure)
  

64475 --  ... lumbar or sacral, single level
  

64476 --  ... lumbar or sacral, each additional level (list separately in addition to code for primary procedure).

   
Codes 64470 and 64475 describe different locations on the spine, but both are used to report the first injection made in the appropriate area (i.e., cervical or thoracic for 64470, lumbar or sacral for 64475). Whether the facet joint or the median branch nerve receives the injection, the same code is used, says Patricia Bukauskas, CPC, a pain management coding and reimbursement specialist and CEO of TB Consulting, a coding and reimbursement company in Aliquippa, Pa. Codes 64472 and 64476 should never be used on their own because they are "add-on" or "list in addition to" codes, which are identified in the CPT manual by a "+'' on the left margin.
      
Tip 1. Don't append modifier -51 to add-on codes. Modifier -51 (multiple procedures) should not be attached to 64472 or 64476 because, as add-on codes, the fees for these services are already reduced (although not by much: 64472 and 64476 are valued at 5.01 and 5.20 RVUs, respectively; their parent codes, 64470 and 64475, are valued only marginally higher, at 5.91 and 5.27 RVUs).
   
Appending modifier -51 may prompt your payer to inadvertently (and incorrectly) reduce the fee by 50 percent, which is normally is the case with multiple procedures. 
 
Note: Even when true multiple procedures are performed, the carrier may prefer that modifier -51 not be appended to the second or subsequent code(s). Many payers automatically discount second and third procedures and/or apply modifier -51 themselves, so ask your carrier if modifier -51 is still necessary.
 
Tip 2. Use modifier -50 and charge more for bilateral procedures. Until April 1, 2000, injections given on both sides of the facet joint could not be reported with modifier -50 (bilateral procedure) appended to the appropriate CPT code. In the 2001 version of CMS' National Physician Fee Schedule Relative Value Guide, however, 64470-64476 all have a "1" indicator in field W, which means they can be billed bilaterally.
 
According to Noridian Mutual Insurance Co., the Medicare carrier for Alaska, Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming, "Each CPT code listed (single level, each additional level) may be billed with a modifier -50 when injecting a level bilaterally." Procedures correctly reported with modifier -50 attached are usually paid at 150 percent of the normal fee, says Martina Heasley, CPC, an administrator in the department of anesthesia at Stanford University in Stanford, Calif.
 
Coders should not assume, however, that the carrier will automatically increase the fee because modifier -50 is appended. "Some computer systems may not be set up to recognize modifier -50 and automatically increase the fee to 150 percent, so you should remember to manually increase the fee charged for the procedure on the claim form," Heasley says.
 
She does not recommend billing the procedure at 200 percent of the fee and letting the carrier reduce payment to 150 percent, because that would harm the practice's collection ratio.
 
Commercial carriers often require two lines for modifier -50 claims. In such cases, it may be preferable not to cut the second line by 50 percent, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist in Lakewood, N.J. "If you cut the fee for the second procedure, some carriers may incorrectly assume that the second line is for a duplicate procedure and cut the fee even more," she says, adding that coders should check the carrier's explanation of benefits (EOB) to make sure payment has not been reduced inappropriately.
 
Tip 3. Medical necessity must be documented to support multiple injections. Most carriers allow a maximum of three injections, each at a different level, per session. The number of injections over a period of time  may also be limited. For example, Aetna U.S. Healthcare, a large private payer, instructs physicians that "facet joint injections should be limited to a maximum of three sets of injections over a 12-month period." (Aetna defines one set as treatment of a maximum of three anatomical sites at one session, such as different levels or different sides.)
 
Sometimes, carriers may allow more than three injections per session, but you must have clear and accurate documentation that supports the medical necessity of the multiple injections. According to the LMRP from Empire Medicare Services, the local Medicare carrier in New Jersey and parts of New York, "Provision of more than three levels of facet joint blocks to a patient on the same day is not considered medically necessary." But the same LMRP also states that "Claims for an unusually large number of facet nerve blocks will be denied as not medically necessary in the absence of supportive documentation."
 
Empire appears to be saying that providing supporting documentation may permit more than three injections per session, but only if the facet nerve (i.e., the median branch nerve) is injected. More than three facet joint injections, meanwhile, are considered not medically necessary.
 
However, many carriers consider the two procedures interchangeable, particularly because both are reported using the same code, and are unlikely to make such a fine distinction between them, says Devona Slater, CMCP, an associate of Auditing for Compliance and Education (ACE Inc.), a pain management coding and compliance consulting firm in Leawood, Kan. Ask your carrier for its policy.
 
Tip 4. Watch vertebral levels and check your EOB. Most carriers consider multiple injections on the same level as one procedure. For example, an LMRP from National Heritage Insurance Company, the Medicare Part B carrier for California, Maine, Massachusetts, New Hampshire and Vermont, states that "[a facet joint injection] is considered a single procedure whether or not it is performed as a single injection (intra-articular route) or more peripherally and blocking the articular [i.e., median branch] nerves with two injections."
 
Two injections are required to block the median branch nerve inside the joint because the facet joint sits between two levels, with one nerve at the top of the facet joint and a second nerve at the bottom of the joint. Therefore, blocking the median branch nerve inside the facet joint involves two separate injections into two distinct nerves. As a result, when the nerves are blocked, some physicians mistakenly believe the code may be billed twice, with one injection relating to the level above and the other to the level below.
 
Whether the joint or nerves were blocked, only one injection may be billed, Slater says. "Some physicians have problems with the word 'level,' as do carriers, who often pay for only one level or somehow skip levels," she says.
 
Because the facet joint is between two levels (for example, between level 2 and level 3, or L2-L3), the correct "level" for facet joint or median branch injections is L2-L3, which should be the location noted in the operative report for a facet joint or median branch nerve injection.
 
Because carriers may misinterpret what the physician did, Slater urges coders to check the EOB carefully for these procedures. "If you don't micromanage and don't watch those EOBs, you'll lose money," she says.
 
Tip 5. If the patient has documented multiple pain conditions, other pain injections may be paid. Medicare carriers typically will not pay for other injections, such as epidurals or sympathetic blocks performed during the same session as a facet joint injection. For example, if the patient has disc-related pain and receives a lumbar or sacral epidural steroid on the same day as a facet joint injection, the epidural will not be paid, Bukauskas says.
 
The carriers' rationale for these denials, she says, is that the facet injection is often diagnostic, and if another anesthetic or steroid is also injected, the diagnostic results will be unclear.
 
The fact that many carriers routinely deny other injections -- i.e., epidural blocks, bilateral sacroiliac joint injections and lumbar sympathetic blocks -- when performed during the same session as facet injections has drawn the ire of many physicians who note that multiple injections can be helpful when performed therapeutically. 
 
But the therapeutic, as opposed to the diagnostic, use of multiple injections has also been recognized by some carriers, such as Palmetto GBA, the Medicare Part B carrier in South Carolina.
 
In its facet joint injection policy, Palmetto states that "multiple nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient." The policy goes on to say that performing these different injections "or providing more than three levels of facet joint blocks to a patient on the same day is not considered medically necessary if being used as a diagnostic procedure.

Such therapy can lead to an improper diagnosis or unnecessary treatment. If, however, the diagnosis has been established and the patient has more than one diagnosed pain condition, it is reasonable to perform more than one injection to give the patient maximum pain relief and avoid the cost and inconvenience of having to do the blocks on separate admissions." [emphasis added]
 
For such a claim, the physician's procedure notes should clearly document that the facet joint injection was therapeutic, not diagnostic. The operative note should also include a short section to indicate why the injections were medically necessary.
 
Tip 6. Use fluoroscopy code 76005. Until 2000, the only fluoroscopy code for guidance during pain injections was 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]). CPT 2000  introduced 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).
 
76005 is more appropriate whenever a facet joint or nerve injection is guided by fluoroscopy, and it also pays better (1.61 RVUs for 76000, compared with 2.08 RVUs for 76005). Some carriers may not have updated their LMRPs, which may still instruct physicians to use 76000. This instruction should probably not be followed, as 76005 is a more accurate code, but carriers should be contacted to be certain.
 
Note: If the injection is performed in the hospital, append modifier -26 (professional component) to 76005 if the pain physician performed the fluoroscopy.

ICD-9 Codes and Documentation

 
Carriers may differ on the length of time that must pass before pain can be described as "chronic." According to Aetna U.S. Healthcare, for example, three months must pass; for Noridian, it is six months. Anything less than the designated time frame is usually described as "acute" pain.
 
The distinction is important because some carriers want to see an indication of chronic pain before they approve facet joint injections, Bukauskas says. Others, such as Palmetto, accept "suspicion of facet joint pain" as a valid indication.
 
The ICD-9 codes accepted by different carriers as providing medical necessity for the injections also vary greatly. Although 721.3 (lumbosacral spondylosis without myelopathy) is acceptable to most carriers, other codes in the 720 range are acceptable to some carriers but not others. Ask your carrier for a list of appropriate diagnosis codes.
 
If the service has been provided for a diagnosis that is not listed in the covered ICD-9 codes section of the LMRP, the provider must thoroughly document the medical necessity and rationale for providing the service in the patient's medical records. Claims like this should include a statement such as "Medical necessity documented in the patient's medical record" on the comments line of the electronic HCFA claim form. If a paper claim is sent, documentation should be sent with the claim form.
 
Documentation should include the preoperative evaluation that led to the suspicion of the presence of facet joint pathology, as well as postoperative conclusions, Bukauskas says. "Medicare now wants the documentation for these injections to resemble that of an operative report, including pre- and post-op diagnoses and conclusions," she says.
 

Therapeutic Reasons Affect Coding
 
Most Medicare carriers do not cover nerve blocks administered by any means other than an injection of anesthetic agents through a needle, including the use of "noninvasive" or "electromedical" devices, such as Matrix, that administer a type of nerve block by means of electricity.
 
If the median branch nerve is destroyed for therapeutic reasons, any facet joint or nerve injection performed is included in the appropriate destruction code (64622-64627, as determined by location and number of levels) and should not be billed separately.
 
Note: Version 7.2 of the national Correct Coding Initiative bundles 64470 with 64626, and 64475 with 64622.