Anesthesia Coding Alert

Spinal Injection Coding, Part 2:

Check Documentation Details for Injections

Published on Fri Nov 07, 2003

Treatment stage, modifiers and other services matter

Last month, we discussed the importance of having a referral for treatment, ensuring medical necessity and coding all parts of the actual procedure for spinal injections. But don't stop there! Make a big difference in your bottom line by knowing the patient's treatment stage, when to separately report a corresponding E/M service, and when you can charge for multiple pain procedures.

Know the Patient's Treatment Stage

Patients rarely have a single epidural steroid injection (ESI) without follow-up injections, so you need to know what stage of the process the patient is in when you're coding. If an initial injection works well, the follow-ups will maximize this effect. If the initial injection works poorly, the physician will often attempt a second injection before abandoning this treatment approach.

"The first visit includes a review of systems (ROS), physical exam and medical history," says Terry Garcia, a coder with Tejas Anesthesia in San Antonio. "Then the doctor determines whether the patient would benefit from the injection. On follow-up visits, the doctor evaluates the patient to check whether he or she has improved. The physician administers the second treatment injection and determines whether a third visit is necessary."

A physician typically administers one ESI per session, unless the patient also has lumbar and cervical pain. Then the physician administers one injection per site for each visit. You report the same codes (62310 or 62311) as for the initial ESI and file each visit on a separate claim.

Timing Is Everything

Timing the sessions depends on the exact procedure and how well the patient responds (it can take one or two days after the injection to know whether it worked). The physician can administer an ESI as a single injection or in a series, but Robin Fuqua, CPIC, a coder for Jose Feliz, MD, in Escondido, Calif., says they are usually most effective in a series of three injections spaced two weeks apart. If the first two injections don't help, the physician doesn't typically administer a third.

"Some patients get such significant relief from the initial injection that they wait several months before having another," says Tammy Reed, anesthesia department billing manager for Oklahoma University Health Science Center in Oklahoma City. "Other patients go through a series of injections in order to reach the maximum amount of pain relief. Some patients don't get relief from the ESI and don't repeat the injections."

Patients who don't get relief from ESIs might be candidates for other procedures such as implanting a continuous infusion pump or implanting electrodes.

Whatever stage of the process the patient is in, you can report a separate code for an E/M visit if the physician administers the injection in an outpatient or office setting. "Any injection can be done with an E/M service as long as you're seeing the patient for two different reasons and have separate reports with documentation to back up the legitimacy," Fuqua says.

You'll code the most appropriate choice from the new or established E/M codes in most situations (99201-99205, Office or outpatient visit for the evaluation and management of a new patient, or 99211-99215, Office or other outpatient visit for the evaluation and management of an established patient), Reed says. But there may be times when the referring physician asks the anesthesiologist to evaluate the patient and recommend but not begin immediate treatment. In that case, you'll code for a consultation (99241-99245, Office consultation for a new or established patient) instead of a standard office visit.

Decide on the Best Modifier - if Any

You can report two services if a physician administers a pain management injection during an E/M visit or if he administers two different types of injections during the visit - if you can master your modifiers. Keep these points in mind when you're deciding how to code the procedures:

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) - Append modifier -25 to an office visit code when the physician gives the injection during an E/M visit, especially if the E/M coding represents the majority of the visit (such as the patient's initial appointment).

Modifier -51 (Multiple procedures) - When a physician performs two procedures in the same operative session (such as multiple injections to the spine), append modifier -51 to the secondary service, unless you're dealing with a Medicare carrier. Medicare does not want you to use modifier -51 at all; instead, they append it during processing to determine whether a service is subject to a multiple-surgery reduction. Some smaller carriers might require modifier -51 for multiple procedures, but most don't.

Modifier -59 (Distinct procedural service) - There are some procedures that physicians don't normally perform together in a single surgical session. Even when the physician does perform both services, you can't usually charge separately for them.

Reporting modifier -59 indicates that you know the two services aren't normally performed together but that the procedure you append it to was distinct or separate from the other service(s) provided in the same session (such as injections to more than one site - the lumbar spine, shoulder or neck - or a second type of procedure). But since this is the modifier coders use to unbundle CCI edits, be sure your documentation clearly indicates that the service wasn't part of the more comprehensive procedure. Most carriers (other than Medicare) want to see operative notes when you report modifier -59, which means you need to submit a paper claim for the case.

Verify if Other Services Are Performed

If the physician administers the ESI for diagnostic purposes, the injection is probably the only service he performs during that visit. As Reed points out, many carriers will pay for only one diagnostic service per anatomic area per session. This is to make certain that the physician can effectively treat any problems that are detected - it may be impossible to determine which treatment works best if the physician performs multiple diagnostic or treatment services during the same session.

When the ESI is therapeutic, the physician may also administer another type of injection during the same session, such as a facet (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; or +64476, ... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]) or SI joint injection (27096, Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid).

The physician might also inject trigger points (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s], or 20553, ... single or multiple trigger point[s], three or more muscles) to relieve neck or shoulder pain while giving a lumbar epidural for lower back pain (or pain in some other area of the back).

Some coders ask their physicians not to perform multiple services during the same session because of bundling guidelines, but the physicians might do it anyway. In this case, Garcia recommends coding only for the major (or highest base) procedure: the ESI.

"Our biggest challenges when coding spinal injections are making sure that medical necessity for Medicare patients is documented and that the correct levels are identified," Reed says. "We review the operative report and compare the coding with the carrier's LMRP before submitting the claim."