Neurology & Pain Management Coding Alert

Epidural blocks provide effective pain management for patients with spine-related injuries or illnesses. But reporting these procedures and collecting payment can be difficult. Codes must be selected according to the spinal area injected, and medical necessity must be established through the use of approved diagnoses. Also, multiple injections and/or additional services may be provided at the same time as an epidural block but are not always separately billable.

Epidural blocks are administered to reduce pain and inflammation or to confirm a diagnosis. Initially, a local anesthetic is given. A needle is introduced to the epidural space, through which an anesthetic, steroid, antispasmodic and/or neurolytic agent is injected. These injections are commonly used to treat nonsurgical spinal conditions (e.g., sciatica), but are also effective in managing postsurgical pain or non-spine-related afflictions.
 
The procedures are reported using four code groups (62280-62282, 62310-62311, 62318-62319 and 64479-64484), depending on the agent and method of injection. Within each group, individual codes are differentiated according to the targeted spinal area cervical, thoracic, lumbar or sacral.

The first epidural block code group is used to report the injection of neurolytic substances, agents that destroy nerves:

62280 injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid

62281 epidural, cervical or thoracic

62282 epidural, lumbar, sacral (caudal).

These injections are given to destroy damaged nerves that are the source of a patient's pain or to affect adhesions following surgery, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J.
 
Report 62280 for injections to subarachnoid space, regardless of the spinal level. This is the area beneath the arachnoid membrane (the middle of the three coverings surrounding the central nervous system), which lies below the dural layer. Epidural injections, which are closer to the skin, are differentiated by spinal level. Because of these distinctions, coders working from physician notes must encourage neurologists to document the depth and location of injections, Brink says. 

The second and third code groups describe trans-laminar (either epidural or subarachnoid) epidurals, says Francis Lagattuta, MD, chairman of the CPT nonoperative coding committee for the North American Spine Society and a board member of the American Association of Electrodiagnostic Medicine. The first of these groups describes a single injection of substances other than neurolytic agents:

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

62311 lumbar, sacral (caudal).
 
 
Codes 62310 and 62311are also distinguished according to the spinal level where the injection is provided. Documentation should include this specification.
 
Injections via indwelling catheter of substances other than neurolytic agents are similarly reported. These codes include catheter placement:

62318 injection, including catheter placement, continuous infusion or intermittent bolus, 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

62319 lumbar, sacral (caudal).

The final code group describes transforaminal injections. Unlike the translaminar approach, which places the medicine inside the epidural space, a transforaminal injection places the medicine from the outside of the epidural space and tracks it into the epidural space at specific levels. The most commonly used codes in neurology are:

64479 injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level

64480 cervical or thoracic, each additional level (list separately in addition to code for primary procedure)

64483 lumbar or sacral, single level

64484 lumbar or sacral, each additional level (list separately in addition to code for primary procedure).
 
In this case 64479 and 64483 are the primary codes and should be reported for the first injection to the cervical/thoracic or lumbar/sacral levels. Add-on codes 64480 and 64484 are for each additional injection at the cervical/thoracic or lumbar/sacral levels. As add-on codes, they are modifier -51 (multiple procedures) exempt, and if it is appended, a fee reduction may result.

Unlike the transforaminal epidurals, there are no add-on codes to report multiple injections when administering a neurolytic substance or translaminar epidural. When billing for these services, report each injection separately with modifier -51 appended to the second and subsequent codes. For instance, if the neurologist provides two epidural injections of a neurolytic substance one each at a cervical and lumbar level the service should be reported 62282, 62281-51. Documentation must support each code independently, outlining the dosage, location and medical necessity for each injection.
 
If the neurologist combines two substances in a single injection, however, only one injection code is appropriate. Pay close attention to medical terminology and interpret documentation carefully. For example, Brink says, if the neurologist gives the location of the injection as C2/C3, the coder must know that this represents a single injection at the interspace of two vertebra, not two separate injections.
 
Many carriers limit the number of injections or injection combinations that they will accept as medically necessary in a single session. For instance, Palmetto GBA policy #98-0020-L, which covers epidural injections for South Carolina, specifies, "Providing epidural block, multiple facet joint blocks, bilateral sacroiliac joint injections, and lumbar sympathetic blocks in any combination to a patient on the same day for diagnostic purposes is not medically necessary."
 
In addition to multiple injections, other services may be provided at the same time as an epidural block. For example, fluoroscopic guidance (76005) is commonly used to ensure proper placement of the needle, Brink says. The Physician Fee Schedule includes relative value units for the professional and technical components of 76005. Therefore, says Kathy Pride, CPC, CCS-P, an HIM applications specialist and coding and reimbursement expert with Quadramed, a California-based consulting firm, if the physician does not own the equipment with which the fluoroscopy is provided, attach modifier -26 (professional component). Injection of contrast during fluoroscopic guidance and localization is an inclusive component of 62280-62282 and 62310-62319 and should not be separately billed.
 
Code 76005 is a "regional" code, Lagattuta says. Therefore, when performing multiple injections in a single spinal area (e.g., cervical, thoracic, lumbar), bill 76005 once. If multiple injections are provided at different spinal areas (e.g., one injection at the cervical level and one at the thoracic level), they may be reported twice. For those insurers who mandate its use, modifier -51 must be appended to the second and subsequent codes.
 
An E/M service provided on the same date as an epidural block may be charged if it is significant and separately identifiable. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) must be attached to the appropriate E/M code. For example, a patient presents for an injection but also complains of symptoms resembling carpal tunnel syndrome. The neurologist provides the injection and spends 15 minutes examining the patient as a result of the new complaint. For this visit, code the injection (e.g., 64479) and the E/M service (e.g., 99213, office or other outpatient visit for the evaluation and management of an established patient), with modifier -25 appended to the latter. The medical record should reflect the separate nature of the E/M service.

Establishing medical necessity for epidural blocks depends largely on the attending diagnosis(es), Lagattuta says. Carriers specify varying guidelines regarding diagnoses they will accept to support codes 62280-62282, 62310-62319 and 64479-64484, but the following represents a typical list:

053.19 postherpetic neuralgia

140-239.9 neoplasms

337.xx reflex sympathetic dystrophy

354.4-355.8 mononeuritis

722.0-722.11 displacement of intervertebral disc without myelopathy

722.71 intervertebral disc disorder with myelopathy, cervical region

722.72-722.73 intervertebral disc disorder with myelopathy, thoracic, lumbar

722.82-722.83 postlaminectomy syndrome

723.4 brachial neuritis or radiculitis NOS

724.3 sciatica

724.4 thoracic or lumbosacral neuritis or radiculitis, unspecified

805.00-805.6 spinal closed fracture

905.1 late effect of fracture of spine and trunk

953.0-953.3 injury to nerve root

V58.9 unspecified aftercare.

Contact your individual insurer or visit www.lmrp.net for a complete list of acceptable diagnoses. Some insurers will give individual consideration for codes that do not appear on the "accepted list." For example, Palmetto GBA policy # 98-0020-L states, "If the service has been provided for a diagnosis that is not listed in the [policy], the provider must thoroughly document the medical necessity and rationale for providing the service for the unlisted diagnosis in the patient's medical records."