Neurology & Pain Management Coding Alert

Follow these 4 tips for reporting E/Ms and associated procedures

If you want to optimize your epidural block coding, you can't afford to overlook opportunities to report associated procedures, separately reportable E/M services and medications, experts say. Follow these four tips to recover all the reimbursement you deserve:

  1. Report fluoroscopy separately with 64479-64484. Codes 64479-64484 do not include fluoroscopic guidance for needle placement, and therefore you may claim this service separately using 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]).
 
Be aware that 76000 is a "regional" code, says Francis Lagattuta, MD, an AMA CPT adviser for the North American Spine Society (NASS) and chairman of the NASS Nonoperative Coding Committee. This means that you should report 76000 only once per general spinal area (cervical, thoracic, lumbar or sacral), not once per injection. For instance, if the neurologist administers two lumbar injections under fluoroscopic guidance, you should report 64483 for the first injection, 64484 for the second injection, and 76000 (one unit) for fluoroscopic guidance of both lumbar injections.
 
If the physician provides multiple injections at different spinal areas, such as one injection at the cervical level and one at the thoracic level, you may report 76000 twice (once per spinal region). For example, for one injection at the thoracic level and one at the lumbar level, report 64479, 64483 and 76000 x 2.
 
Note: Codes 62280-62282 and 62310-62319 include injection of contrast during fluoroscopic guidance and localization as an inclusive component. You should not report 76000 separately with these codes.

  2. Claim E/M services, when applicable. You may charge an E/M service on the same date as an epidural block if the E/M service is significant and separately identifiable, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. You must append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M code.
 
For example, suppose a patient presents for an injection but also complains of symptoms resembling carpal tunnel syndrome (354.0). The physician performs the injection and spends 15 minutes examining the patient because 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 99213. The medical record should reflect the separate nature of the E/M service, Cobuzzi says.

  3. Bill for IV medications: On occasion, neurologists offer patients the option of intravenous (IV) sedation prior to the epidural injection to make the procedure less painful, says Marvel Hammer, RN, CPC, owner of MJH Consulting in Denver. Options for coding the sedation are 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous) or, if the physician meets the necessary criteria, 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation).
 
"Many payers, including most Medicare carriers, bundle the sedation code in with the spinal injection code," Hammer says. "However, if your payer considers the sedation bundled, you should still bill for the medication [for example, Versed (J2250)] as long as you have the invoice showing what you paid for the drug." Whoever purchases the medication should capture the reimbursement for it, Hammer says. "Even if you know that the injection code will be denied, you should still bill for the medication, because they can add up over time."

 The only exception to this rule is if another entity, such as a hospital, ambulatory surgery center or clinic, pays for the medication, Hammer says.

 4. Avoid overbilling. Be aware that many insurers limit the number of injections you may charge in a single day, and will deny all excess claims. For instance, Palmetto GBA policy #98-0020-L, which covers epidural injections for South Carolina, specifies, "Providing epidural blocks, 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."