Anesthesia Coding Alert

Stop Floundering for Fluoro Reimbursement

Published on Fri Nov 07, 2003

Take these 4 steps to get 76005 claims paid

If you're suddenly facing a flood of denials for fluoroscopy claims, you're not alone. Before you give up or attempt to use modifier -26 (Professional component) to circumvent another fluoroscopy bundle, follow these four steps to get your pain management specialist's fluoroscopy claims paid.

Step 1: Be Sure You Use the Correct Fluoro Code

Most fluoroscopy services performed by anesthesiologists or pain management specialists fall under code 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). However, don't automatically rule out CPT's three other fluoroscopy codes: 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]), 76001 (Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]) and 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]).

Before you use 76005, be sure that one of the other codes doesn't apply instead. Most pain management specialists don't have the clinical situations to report 76000 or 76003, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver, but it never hurts to be sure.

Step 2: Verify Whether Edits Apply

Verify whether the applicable fluoroscopy code is subject to any NCCI (National Correct Coding Initiative) edits or bundles. Hammer says 76000 and 76003 are bundled with most codes, but that shouldn't affect pain specialists much because 76005 is the correct code for spinal injections or procedures.

And that's where the problem with 76005 denials appears. Some commercial carriers - such as Blue Cross and Champus - and some workers' compensation plans are suddenly denying claims with 76005 despite the addition of modifier -26 to unbundle the codes. And while some coders say they've had reimbursement problems since CPT 2000 added 76005, many believe the trend seems to be on the upswing.

This new trend potentially means big losses to the physician's bottom line because fluoroscopy is so common. "My clients perform some type of radiologic verification for the vast majority (about 95 percent) of all spinal procedures," Hammer says. "The only exception is 62273* (Injection, epidural, of blood or clot patch).

"Reimbursement for Colorado RBRVS 2003 for 76005-26 is $28.51, and the fee schedule for workers' compensation for Colorado is $64.48. These denials really do affect the bottom line because of the large percentage of injections performed with fluoroscopy." (Of course your reimbursement baseline varies depending on your local factors and your carrier contracts.)

Step 3: Learn How to Handle the Bundles

NCCI edits earlier this year did bundle 76005 with some common procedures, but assigned the groupings modifier indicator "1" so you could unbundled the codes and get paid. These include:

62263 - Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days

62264 - ... 1 day

62284* - Injection procedure for myelography and/or computed tomography, spinal (other than C1-C2 and posterior fossa)

62287 - Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumbar (e.g., manual or automated percutaneous diskectomy, percutaneous laser diskectomy)

62291* - Injection procedure for diskography, each level; cervical or thoracic.

So if NCCI says there's a way for anesthesiologists to get paid for fluoroscopy, why the denials? Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C., and other coders haven't been able to trace the bundle back to a specific version of NCCI edits.

Hammer hasn't found a related NCCI edit either, and believes the denials stem from a bundling edit into the facility payment groups instead. "According to my NCCI edit reference material, 76005 was not bundled into most procedures," she says. "It may be that it was bundled into payment groups for the facility side (outpatient and ASC locations), but it is not listed in the NCCI as being bundled into any of the typical spinal procedures."

These "typical spinal procedures" include 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid), 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 62311 (... lumbar, sacral [caudal]). But the other fluoroscopy codes are bundled with these procedures, which is why it's important to know which fluoroscopy code can be billed with which procedure.

Hammer adds that another possible reason for denials is that some commercial carriers create their own bundling "black box" rules and do not follow NCCI. For example, she says, Aetna has routinely bundled the fluoroscopy code with the procedure code during the past several years. Whether you can appeal the denial depends on the provider's carrier contract and its stipulations.

Step 4: Be Proactive With Denials

Although Hammer has not succeeded in appealing 76005 denials with some carriers, she is optimistic about working with other payers such as the State Division of Workers' Compensation to establish a position on the bundling. If you're fighting fluoroscopy denials in your own practice, keep these tips in mind to help smooth the process:

Check the NCCI edits to learn whether the appropriate fluoroscopy code is bundled, and see if appending modifier -59 (Distinct procedural service) will allow it to be unbundled from the procedure.

Make an effort to educate carriers by sending them a copy of the fluoroscopy CPT descriptor.

Request documentation from carriers regarding what bundling software they use. This gives you the basis for any appeals. "If the payer states it follows X.XX version of NCCI, and that specific version doesn't bundle the codes, then you have a basis to appeal a denial," Hammer says. "If the carrier says they create their own 'bundling' edits, learn what basis they have for those edits (such as specialty societies). Then you can determine if the edits are valid and whether you have a foundation source to appeal with."

Bukauskas-Vollmer adds that the carrier must prove in advance (from its contract or carrier's manual) that the fluoroscopy is a bundled service. If it is, you'll know to negotiate for a higher rate in your next contract.

If you append modifier -26 (Professional component), clarify that this modifier refers to the provider's services rather than the facility's services. Modifier -26 indicates that you're billing only for the professional component of the code and that the provider does not own the fluoroscopy equipment and/or does not employ or pay for the fluoroscopy technician. Bukauskas-Vollmer usually reports only modifier -26 for the professional component and appeals any denials. If the office owns the equipment, and the physician performs both the professional and technical components, she might add modifier -59 (Distinct procedural service) "as a last resort." She and Hammer both caution that your main concern is coding for compliance rather than coding for reimbursement, so be sure the case merits appending modifier -59 before you report it.

Discuss bundling of these types of procedures when you negotiate contracts.