Neurology & Pain Management Coding Alert

Many factors influence the difficult and critical choice of assigning a CPT code for a spinal injection, and the wrong choice can lead to denials or far-less-than-optimal reimbursement. Spinal injections can be performed for either therapeutic or diagnostic reasons, using neurolytic or non-neurolytic substances. Additionally, a variety of areas in the spine may serve as the injection site. At times it is correct to bill separately for fluoroscopy, while at other times it is not. Spinal injections given at additional levels are sometimes, but not always, reimbursable. By examining key areas of the procedure and working with the neurologist, coding professionals can better determine which code(s) best fits each situation.

Understand How to Code Diagnostic vs. Therapeutic Injections

The first step to coding a spinal injection correctly is to determine whether it was performed for diagnostic or therapeutic purposes. Diagnostic injections such as code 62270 (spinal puncture, lumbar, diagnostic) are used mainly to help identify sources of pain or infection. Code 62263 (percutaneous lysis of epidural adhesions using solution injection [e.g., hypertonic saline, enzyme] or mechanical means [e.g., spring-wound catheter] including radiologic localization [includes contrast when administered]) may also be used for diagnostic purposes for lysis of epidural adhesions. Therapeutic injections like 64400-64484 (anesthetic injections to somatic nerves), 64505-64530 (anesthetic injections to sympathetic nerves), 64600-64680 (neurolytic injections) or 62310-62311 (non-neurolytic epidural injections) are used to relieve pain or muscle spasms.

For example, a patient may have lower back pain (724.2) that physical therapy or other more conservative treatments do not alleviate. The neurologist may decide to perform a diagnostic spinal puncture, lumbar (62270) to aid in diagnosis. In another situation, a neurologist performs four stellate ganglion injections for limb pain (729.5) in a patients arm. He or she uses a single syringe and does not refill it between injections, but simply moves the needle and injects through adjacent skin at the C-6 vertebral level.

This injection would be billed using 64510 (injection, anesthetic agent; stellate ganglion [cervical sympathetic]). With 64510, the stellate ganglion block is used to provide anesthesia to the face, neck and upper extremity, says Sylvia Albert, CPC, president of the Tidewater chapter of the American Academy of Professional Coders (AAPC), and a customer support manager at the AcSel Corp., a physician reimbursement firm in Virginia Beach, Va. Code 64510 is based on the number of injections. If multiple injections are done, it is appropriate to report the code and change the units to refer to the number of nerves injected. But, says Albert, it would not be appropriate to code 64510 with modifier -51 (multiple procedures,). Modifier -51 is applicable when multiple related procedures are performed and there is no single inclusive code available.

Neurolytic vs. Non-neurolytic Substance Coding

Another major factor in correct coding for spinal injections is knowing whether a neurolytic or non-neurolytic substance was injected. These can include neurolytic medications such as phenol, alcohol and iced saline or non-neurolytic substances like anesthetics, antispasmodics and steroids.

Neurolytics (codes 64600-64680) are used for permanent nerve destruction. They kill the nerve rather than simply numb it. Because of their permanent nature, neurolytic procedures most often are performed when more traditional forms of pain treatment have not alleviated the patients pain.

Non-neurolytic medications are used for the temporary relief of low back pain or radiating pain. These can include codes for combination anesthetic/steroid injections such as 62310-62311 and 62318-62319.

Identifying the Location of an Injection

Coders should know precisely where the injection was administered to code properly. In addition to understanding the general area of injection (cervical, thoracic or lumbar level), coders should also determine whether the needle was placed in the epidural space or the subarachnoid space. This can be difficult because although neurologists document entry into the epidural space, many do not document entry into the subarachnoid space.

Knowing a little basic spinal anatomy will help coders determine the area that was accessed. The protective matter around the spinal cord is made up of three layers the outer layer is the dura mater, the middle layer is the arachnoid, and the inner layer is the pia mater. The epidural space is between the dura mater and the walls of the vertebral canal. The subarachnoid space is between the arachnoid and pia mater and is where the cerebrospinal fluid is located. Neurologists often refer to subarachnoid injections as intrathecal or subdural.

Follow Four Criteria for Documentation

Coding for spinal injections is like coding for any other type of procedure the more documentation and details in the patients record, the better. If the notes are not as specific as needed, coders should ask the neurologist for more information.

Some of the details that should be included in the patients record are:

1. The specific drug administered (phenol, lidocaine, etc.);

2. The level at which it was administered (L1, L2, T12,
etc.; sites indicated by doctors notes such as L4-L5 refer to the single joint between vertebrae L4 and L5 and would thus represent a single level);

3. The specific locations for each injection when multiples are administered (whether the injections are unilateral or bilateral, on top of each other, etc.); and

4. The purpose of the injection (which nerve branch is
being blocked and why).

Coding Fluoroscopic Guidance

Albert says that if fluoroscopic guidance was performed with the injection to guide needle placement, services would warrant a separately reportable procedure and should be coded 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). No modifier is necessary. According to CPT 2000, injection of contrast material during fluoroscopic guidance is an inclusive component of codes 62270-62273, 62280-62282 and 62310-62319 and therefore cannot be reported separately on those procedures.

Using Add-on Codes Appropriately

Some nerve block codes require an add-on code to be used when billing for more than one level. For example, if the neurologist performs two injections of lidocaine and triamcinolone on C3 and C4 of a whiplash (847.0) patient, he or she would bill 64470 (injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic single level) and +64472 (cervical or thoracic; each additional level).

A lot of times, the doctor will write the code, then x2 or x3 to reflect that he performed the injection on two or three levels, says Karen Duane, CPC, coding specialist for the Barrow Neurological Institute, a 20-neurologist center in Phoenix that is also one of the largest full-service neuroscience centers in the southwestern United States. But that doesnt mean you should automatically bill the initial code with two or three units. You should look first and make sure there isnt a separate add-on code for each additional level, and if there is, you should use that one instead.

Its important to note that the add-on codes for the spinal injections refer to each additional level injected, not the number of units injected. The neurologist would have to move from one level (e.g., C3) to another level (e.g., C4) to justify the use of an add-on code.

Codes 64470-64476 are new, added to the CPT manual in 2000, and are unilateral procedures, meaning that if injections are performed on both the right and left paravertebral facet joints or facet joint nerves, modifier -50 (bilateral procedure) can be used.

Be Careful Using Epidural Injection Codes

Duane points out that CPT 2000 deleted several subarachnoid injection and epidural narcotic injection codes and replaced them with 62310-62319. Although these new codes generally have made coding easier because they are more comprehensive, they have caused many questions in neurology practices.

For example, a neurologist may have used 62289* in 1999 to report injections of antispasmodic drugs into the lumbar region. But, 62289* was a starred procedure, while the code that replaced it, 62311 (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; lumbar, sacral [caudal]) is not starred.

Note: An understanding of how to bill for starred procedures can be found in the article on the next page, Use Modifiers to Increase Payment for Starred Procedures.

Codes 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 are not starred procedures, but are site-specific codes, says Albert. Therefore, if injections (62310 and 62311) are done both in the cervical or thoracic area and in the lumbar sacral area on the same day, both are reportable with modifier -59 (distinct procedural service) on the second procedure.

Codes 64479-64484 were added in CPT 2000 to represent epidural injections and their accompanying add-on codes. These procedures are also considered unilateral, so modifier -50 can be added if the injections are performed on both sides of the spine.

Note: CPT 2000 contains an error that was clarified in the American Medical Associations CPT 2000 Errata publication, which states, The cross-reference following code 64450 inadvertently directs users to the translaminar epidural injection codes 62310-62319. The correct codes for phenol injections are the neurolytic destruction codes 64622-64627.