Neurology & Pain Management Coding Alert

New NCCI edits also restrict reconstruction and brain imaging

If you-re thinking of reporting nerve blocks with chemodenervation and nerve destruction codes, the most recent round of NCCI edits will make you think again. Of the more than 2,500 new bundles created by NCCI 11.3, upwards of 160 are dedicated to keeping you from coding these procedures together.

CMS updates the NCCI edits on a quarterly basis to ensure that -physicians are not bundling for things that would be standard of care,- says Barbara Johnson, CPC, MPC, owner of the consulting firm Real Code Inc., in Moreno Valley, Calif.

CMS explains the reason for this set of new bundles as incorrect coding for nerve block injections in conjunction with neurolytic destruction procedures. Carriers like to see a -reasoned, systematic elimination of the problem,- says Christina Olson, consultant and auditor with South Oakland Services in Warren, Mich. Using a nerve block on the same visit as a neurolytic agent can muddy your case for medical necessity.

Previously, the bundling of a select number of nerve block codes, such as 64415 (Injection, anesthetic agent; brachial plexus, single) and 64417 (- axillary nerve), hinted that a larger group of bundles might be on the way. Any nerve blocks that had been left alone by previous NCCI edits are now scooped up as components for chemodenervation and nerve destruction procedures. This means that nerve blocks are now an included, and not separately billable, part of CPT codes 64612-64681.

Potential pitfall: The only chemodenervation and nerve destruction codes spared from this bundling are add-on codes +64623 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level) and +64627 (- cervical or thoracic, each additional level). However, because these codes must be reported in addition to a primary procedure--and the primary procedures themselves include nerve blocks--the add-on codes will always be stuck in bundles.

Include Reconstruction in Brain Imaging

The new edits also indicate that it's time to change your claims for brain imaging if they include 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computed tomography, magnetic resonance imaging, or other tomographic modality) or G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).
 
Reconstruction of tomographic/MRI (76375) data and diagnostic injection (G0351) are now included in the following neuroimaging procedures:

- 78600-78610--Brain imaging
- 78615--Cerebral vascular flow
- 78630-78647--Cerebrospinal fluid flow, imaging
- 78650--Cerebrospinal fluid leakage detection and localization
- 78660--Radiopharmaceutical dacryocystography.
 
NCCI 11.3 also rolls G0353 (Intravenous push, single or initial substance/drug) and G0354 (Each additional sequential intravenous push [list separately in addition to code for primary procedure]) into comprehensive procedures 70010 (Myelography, posterior fossa, radiological supervision and interpretation) and 70015 (Cisternography, positive contrast, radiological supervision and interpretation).

Edits Nix Therapeutic Injections and E/Ms

In addition to limiting your reporting options for nerve injections, NCCI 11.3 rules out the possibility for coding new or established patient evaluation and management services in conjunction with therapeutic or diagnostic injections. This change should constitute only a glancing blow to neurology reporting practices, because most offices do few injections.

As a result of these new bundles, you will not be able to separately report E/Ms in the 99201-99215 range if any of the following injection or drug administration services are also reported:

- 90783--Therapeutic, prophylactic or diagnostic injection (specify material injected); intra-arterial

- 90788--Intramuscular injection of antibiotic (specify), in addition to HCPCS codes

- G0351--Therapeutic or diagnostic injection (specify substance or drug); subcutaneous or  intramuscular

- G0353--Intravenous push, single or initial substance/drug.  

Watch out: While injection codes are often rolled into other procedures, in this case they are the larger, comprehensive codes that the E/M services are bundled into. For reimbursement purposes, however, you still want to let relative value units (RVUs) be your guide when reporting, says Maggie M. Mac, CMM, CPC, CCP, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla. Even the lowest level E/M code, 99211, provides 0.57 RVUs versus 0.50 RVUs for 90783, indicating that you-ll always want to code the E/M instead of the injection code.

Unbundle With Caution

All of the edits mentioned in this article have a status indicator of one, meaning you can unbundle using modifier 59 (Distinct procedural service), when applicable. Example: If you are performing a nerve block and chemodenervation for separate sites, which Olson says is overwhelmingly the case when these codes are reported together, you can append modifier 59 to the second procedure to justify separate reimbursement.

Remember that modifier 59 is considered -the modifier of last resort,- so you should strengthen your case for unbundling by making sure the performed services fulfill one of the following five criteria: different sessions or encounters, different sites/organ systems, separate incisions/excisions, separate lesions, or separate injuries.

For more information: To get your hands on the complete set of NCCI 11.3 edits, visit the CMS site www.cms.hhs.gov/physicians/cciedits or e-mail the editor at alicew@eliresearch.com.