Neurology & Pain Management Coding Alert

Along with new CPT codes, as of Jan. 1 you'll have to learn several new code pairings, thanks to the latest Correct Coding Initiative (CCI) edits which bundle facet joint injections into nearly every procedure. CCI version 16.0 contains a whopping 24,060 new active pairs and 869 modifier changes, according to Frank D. Cohen, MPA, MBB, senior analyst with MIT Solutions Inc.

Many of the latest CCI edits relate to new CPT 2010 codes. The number of CCI bundles relating to new codes is expected, says Susan Garrison, CHC, CHCA, PCS, FCS, CCS P, CPAR, CPC, CPC H, executive vice president of healthcare consulting services with Magnus Confidential, Inc. in Dawsonville, Ga. "It looks unbalanced toward the new codes," she says, "but it's simply a matter of adjusting the edits to make sure the codes are covered appropriately."

Of course, you don't have to memorize every single edit. Here are the top codes your neurology practice will have to watch out for to stay compliant.

CCI now bundles the new 2010 CPT facet joint injection codes (64490-64495) with electromyography (EMG) codes (95860-95875, Needle electromyography ...), according to Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Example: Your patient is scheduled for both a diagnostic 2 limb EMG for muscle weakness in both upper extremities and an L4-L5 intra-articular facet joint injection for increasing axial low back pain on the same date of service by the same neurologist. You'll report the 2 limb EMG with 95861 (Needle electromyography; 2 extremities with or without related paraspinal areas). Then use the new CPT code 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) for the lumbar facet joint injection. As of Jan. 1, CCI bundles 95861 as a column 2 code into 64493 based on the standards of medical/surgical practice CCI edit rule.

These EMG bundling edits all carry a modifier indicator of "0." When "0" modifier indicators are present, "it doesn't matter what the circumstance, you cannot bypass the edit," Garrison says. So if your neurologist is performing the procedures on the same day, your claim will be sunk. Even as in the above example, if your neurologist performs the diagnostic study at a different anatomical location from where he performs the facet joint injection, a "0" indicator means there is no modifier that will allow the column 2 code to process. The payer will deny your EMG diagnostic study, Hammer adds.

Bright spot: You don't have to lose out on reimbursement altogether. Hammer's suggestion: If possible, schedule one of the services, such as the EMG diagnostic study, on a different date of service.

You also won't be able to report the new facet joint injection codes -- 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single level) and 64493 (... lumbar or sacral; single level) -- with other neuromuscular electrodiagnostic testing codes, such as nerve conduction studies (95900-95905).

Example: Your neurologist performs a lumbar facet joint block (64493) with a median sensory nerve conduction study (95904, Nerve conduction, amplitude and latency/velocity study, each nerve; sensory). CCI 16.0 bundles 95904 and 64493 and the edit carries a "0" modifier indicator. Therefore, you cannot bypass this bundling with a modifier. If you bill these codes together on the same date of service for the same neurologist, the payer will deny 95904 as bundled and not separately payable.

In addition, CCI 16.0 bundles 95905 (Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report) into the motor nerve conduction studies (95900 and 95903), sensory nerve conduction studies (95904), and both H-reflex studies (95934 and 95936). These bundles all carry a modifier indicator of "1." Therefore, if your neurologist performs and documents legitimate separate and distinct diagnostic studies, you can bypass the edits with a modifier, Hammer says.

CCI 16.0 also bundles the fluoroscopic needle guidance code series (77002-77003) with a number of procedures your neurologist might perform. For example, you won't be able to report 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) with most of the nerve injection codes, such as 64405 (Injection, anesthetic agent; greater occipital nerve).

Also you won't be able to report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) with the facet joint injection code 64490.

Reasoning: The new 2010 facet joint injection codes include image guidance in their code descriptions: Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT]...

Additionally, these new CCI bundling edits are following the CPT Manual and CMS coding instructions that fluoroscopic needle guidance, when used in conjunction with the new facet joint injection code procedures, would not be separately billable. When your neurologist performs a facet joint injection and uses fluoroscopy to verify the needle placement, the needle guidance is included in the code description and as such is not considered to be separate and distinct image guidance.