Neurology & Pain Management Coding Alert

Most coders err with 64470 and 64475 -- here's how to buck the trend.

The Office of Inspector General (OIG) recently released a report that should have you scrambling to double-check your claims for facet joint injections. The Sept. 17 report indicates that -63 percent of facet joint injection services allowed by Medicare in 2006 did not meet Medicare program requirements, resulting in approximately $96 million in improper payments for physician services.- Avoid becoming a statistic with these tips.

Beware of Office-Based Errors

The OIG report -- -Medicare Payments for Facet Joint Injection Services- -- indicates that 71 percent of facet joint injections performed in physicians- offices contained errors, while only 51 percent of facility-based facet joint injections showed errors.

OIG note: The OIG report noted that more than 60 percent of the errors it found concerned -instances in which the physician billed incorrectly for bilateral facet joint injections.-

For example: Physicians reported add-on codes to indicate that a contralateral side of a spinal level was injected, although they should have simply appended modifier 50 (Bilateral procedure) to the facet joint injection code.

All this puts your neurologist's practice under the microscope. Here's how to dissect facet joint injections correctly and avoid the wrath of the OIG.

First: Add-Ons Apply to Extra Levels

When reporting facet joint injections, you should choose either 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) or 64475 (... lumbar or sacral, single level), depending on the spinal area your neurologist treats.

For each additional level your neurologist injects in the cervical or thoracic area, report +64472 (... cervical or thoracic, each additional level [List separately in addition to code for primary procedure]). For each additional level he injects in the lumbar or sacral area, turn instead to +64476 (... lumbar or sacral, each additional level [List separately in addition to code for primary procedure]).

Second: Clarify Terminology

Although the descriptors for 64470 through +64476 specify spinal levels, your physician actually targets facet joint injection procedures at the space between vertebrae (in other words, the interspace), says Alexandra Cortina with Pain Billing Pros in Clearwater, Fla.

For instance: If your neurologist documents -facet joint injection at C4-C5,- this represents a single injection to the joint between the fourth and fifth cervical vertebrae. However, your neurologist can alternately perform inject-ions of the two paravertebral facet joint nerves (medial branches) that provide sensory information from the single facet joint back to the spinal cord. In this situation, your neurologist performs a total of two injections -- the first at the C4 vertebrae for the C4 medial branch, and the second at the C5 vertebrae to block the C5 medial branch.

According to a Sept. 2004 CPT Assistant article, you should consider these two injections a single level.    

Regardless of whether your neurologist performs a single intra-articular facet joint injection or blocks both paravertebral facet joint nerves for that facet joint, he reports only one CPT code for the single level.

Third: Keep Modifier 50 at Hand

If your neurologist performs facet joint injections at the right and left side of the same spinal level --  the right C5-C6 and left C5-C6, for example -- you should report only a single unit of service with modifier 50 appended for bilateral injections. Just be careful you don't exceed your carrier's utilization guidelines, says Heather Corcoran with CGH Billing.

Watch out: You should not report the bilateral facet joint injections as one unit of the first or single level code, and one unit of the add-on code for -each additional level.- This would incorrectly report the neurologist's bilateral facet joint injections.

-Good- news: The OIG report also showed 29 underpaid services during the audit, and that 100 percent of the undercoded services were instances when the physician billed for unilateral services when he actually performed bilateral injections. That resulted in a 50 percent underpayment, the report said.

For example: Your neurologist injects intra-articularly or directly into the joint at the right and left C4-C5 and C5-C6 facet joints. You should report 64470-50 (for the initial bilateral injection at C4-C5) and +64472-50 (for the additional bilateral injection at C5-C6).

Bottom Line: The OIG's findings emphasize the importance of thorough documentation and correct coding when it comes to bilateral injections. Stay sharp on your injection coding, and you-ll stay on OIG's good side.

Editor's note: To read the complete OIG report, visit http://oig.hhs.gov/oei/reports/oei-05-07-00200.pdf.