Neurology & Pain Management Coding Alert

Proper coding for epidural blocks requires knowledge of the various clinical procedures that may be involved in the patient encounter. Although revisions in CPT 2000 served to simplify these spinal injection codes, the changes have created some confusion in the neurology community. Understanding these changes and procedures will help you achieve proper reimbursement for your neurology practice.

Epidural blocks are used by neurologists for pain management of nonsurgical conditions or, in rare cases, for acute postsurgical pain. The vast majority of these services are for spine-related problems, asserts Francis Lagattuta, MD, chair of the CPT nonoperative coding committee for the North American Spine Society (NASS) and member of the board of directors of the American Association of Electrodiagnostic Medicine (AAEM).

An epidural block involves the use of a needle or catheter to insert a substance into the space surrounding the spinal cord (subarachnoid or epidural). The injections might include one or more substances, such as anesthesia, steroids, antispasmodic or neurolytic agents.

CPT Code Changes

With the changes in CPT 2000, certain codes used to report epidural blocks now are grouped into four families. Probably the most significant change to epidural block coding was the addition of codes 62310-62319 and codes 64479-64484, reports Lagattuta. These two groups of codes are distinguished on the basis of the direction of approach for needle insertion. The new 62310-62319 codes are used to report translaminar epidurals, while the new 64479-64484 codes were created for transforaminal epidurals, he continues.

One thing the new CPT codes were intended to accomplish was simplification in reporting epidural procedures, claims Lagattuta. For this reason, within each of these families (62310-62311, 62318-62319, 62280-62282, and 64479-64484), the codes are differentiated on the basis of location on the spine, whether it be cervical, thoracic, lumbar or sacral.

Of all these epidural block procedures that neurologists might carry out, the majority will be for conditions such as sciatica (724.3) using code 64483 (injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level). Code 64484 (each additional level) is an add-on code to be reported for every injection given beyond the primary procedure. Similarly, code 64479 describes transforaminal epidurals in the cervical or thoracic region, while 64480 is an add-on code for supplementary injections.

The two families of codes used to report translaminar epidural blocks involving the injection of anesthetics and/or steroids are the new codes 62310-62311 and 62318-62319. Both of these families refer to subarachnoid or epidural injections of substances other than neurolytic agents, reports Karen Duane, CPC, coding specialist for the Barrow Neurological Institute, one of the largest full-service neuroscience centers in the southwestern United States, with 20 neurologists in Phoenix. The new codes replace codes 62274-62279, which were used to report injection of diagnostic or therapeutic anesthetic or antispasmodic at various locations of the spine using different injection methods. These new codes also replace codes 62288-62289 and 62298, which were used to report the injection of steroid substances.

The difference between the new code families of 62310 and 62318 is how the substance is given, says Duane. Codes 62310 and 62311 are for injection, single (not via indwelling catheter), while codes 62318 and 62319 are for injection, including catheter placement, continuous infusion or intermittent bolus. Again, within each of these families, the two codes distinguish whether the injection takes place in the cervical or thoracic region of the spine (the first code in each family) or the lumbar or sacral region (the second code in each family).

The family of codes used to report the injection of neurolytic agents into the spine is 62280-62282, says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc., a practice management and reimbursement consulting firm in Spring Lake, N.J., that consults with several neurology practices. Code 62280 reads injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid. Code 62281 is used to report the similar epidural procedure carried out in the cervical or thoracic region, and 62282 for the lumbar or sacral region of the spine. This type of epidural block may be given to a patient to destroy damaged nerve tissue that is causing the patient extreme pain, she continues. It may also be given postsurgically to break up adhesions.

Coding for Additional Services

Other distinct but related services might be provided at the time of an epidural block and should be coded accordingly. The rules on billing additional services will vary among insurers and Local Medical Review Policies (LMRPs), however, so a coder should check with his or her top carriers for direction, advises Brink.

One example of a distinct service that may be provided in addition to the epidural block is the neurologists initial evaluation of the patient. Evaluation and management (E/M) that is performed as a separately identifiable service on the same day as the epidural block can be reported as such, states Duane. The E/M codes billed on the same day should be submitted with the modifier code -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Fluoroscopic guidance is often employed to help the neurologist pinpoint the exact location for an epidural injection, states Brink. It may be permissible to bill for the fluoroscopic guidance and localization using code 76005. Code 76005 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures) is new in CPT 2000 specifically for use with spinal injection procedures. Prior to this, neurologists had to use the general fluoroscopy codes 76000-76001 to report this service and often were not reimbursed.

Remember that you cannot bill separately for the injection of contrast material with fluoroscopic guidance, warns Duane. The notation following code 76005 in CPT 2000 reads: injection of contrast during fluoroscopic guidance and localization is an inclusive component of codes 62280-62282, 62310-62319.

Theres another new code, 72275 (epidurography, radiological supervision and interpretation), which involves a more in-depth visualization of the epidural space, says Lagattuta. But be aware that this code cannot be reported with, or in place of, code 76005, he cautions. Code 72275 describes a far more complicated procedure that involves generating a report describing contrast flow from multiple views.

Under some circumstances, more than one spinal injection may be given to the same patient on the same day. For codes 64479 and 64483, additional injections are reported using the separate add-on codes (64480 and 64484), says Lagattuta.

For codes 62280-62282 and codes 62310-62319, each service is coded separately, taking care that the medical documentation stating medication, dosage and location and type of injection supports each code, declares Duane. Modifier -51 (multiple procedures) should be appended to the second and subsequent injection codes to indicate that the neurologist performed a combination of procedures at the same session. Further, if a physician combines different medications as opposed to performing two separate injections, the physician should not report two codes.

Brink agrees that coders must be certain of the documentation. Be aware that the neurologist may give the location of the injection based on the space between two vertebral levels, such as L4/L5, she states. Coders need to understand that this does not refer to two separate injection sites, but one injection to the intervertebral space, she continues.

Medical Necessity

It is important to carefully document the medical necessity for these procedures, advises Brink. Duane agrees: Different carriers and third-party payers may have varying guidelines about what conditions warrant epidural blocks, so neurologists and coders should be aware of the local rules. Some commonly acceptable diagnoses include sciatica (724.3), degenerative disk disease (722.x), post-operative spinal adhesions (e.g., 724.4), reflex sympathetic dystrophy (337.xx) and spinal stenosis (723.0 or 724.0x).

Remember, the best way to achieve fair reimbursement for epidural block procedures is to be informed. Coders need to understand the reasons for epidural blocks, as well as the different types of procedures and associated services represented by the updated CPT codes, concludes Duane.