Neurology & Pain Management Coding Alert

Documentation and modifiers are crucial, experts say

Did you know that Medicare bundles many injection procedures, including 20550-20553, 20600-20605, 64400-64430 and 64600-64680, into more complex services, such as nerve blocks? If not, you may be forfeiting reimbursement. Follow these two simple tips to recover all injection payments you deserve.

1. Apply Modifiers to Make the Most of Your Claim

Payers have bundled injections to other, more extensive procedures for years, and the third-quarter 2002 version (8.3) of the National Correct Coding Initiative made many such bundles official Medicare policy. For instance, many nerve block codes (64400-64530) include the trigger point injection codes (20552-20553).
 
This does not necessarily mean, however, that your practice must write off the cost of every injection your physician performs at the same time as other procedures, says Gregory J. Mulford, MD, medical director at Atlantic Rehabilitation Services and chairman of Rehabilitation Medicine at Morristown Memorial Hospital in New Jersey.
 
"The NCCI edits do not preclude use of the modifiers if you perform and document a separately identifiable service on the same day as an injection," Mulford says. He points to modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for injections the physician performs with E/M services, and modifier -59 (Distinct procedural service) for injections the physician performs with other types of procedures.
 
For instance, says Rebecca Savino, office manager at Rehab Health, a solo practice in Waterbury, Conn., "We usually perform E/M services with our injections, and we bill the injection, the E/M with modifier -25 appended, and the J code for the injectable drug." Savino cautions that the E/M service must be a significant additional service, not simply pre- and postinjection care.

2. Separate Injection and E/M Documentation

Most payers will readily pay for both a new patient office visit and an injection, but reimbursement becomes trickier when an established patient is involved, says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Associates in New Brunswick, N.J. Stout advises practices to lift the injection procedure out of the rest of the documentation. "If your notes from the E/M service alone indicate a significant and separately identifiable E/M service, you can submit both codes on your claim. This is a very effective method of stressing the separately identifiable nature of the E/M service." Stout reminds coders to make sure the E/M notes identify the three key elements of history, physical exam and medical decision-making.
 
Common instances when you may separate the E/M and injection documentation include established patients who present for prescheduled injections but also report unrelated problems (such as muscle weakness, 728.87). In this case, the neurologist might perform the scheduled trigger point injection (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]) for neck pain (723.1), a separate E/M service for the muscle weakness, and testing, such as electromyography (95861, Needle electromyography; two extremities with or without related paraspinal areas), also for the muscle weakness.

In this case, you would report: