Neurology & Pain Management Coding Alert

Knowing what to append -- and when -- can help your injection claims.

Last month's issue of Neurology and Pain Management Coding Alert dove into some common injections you might see for interventional pain management -- facet, paravertebral facet, epidural, nerve, and more. Providers might perform many of these injections in conjunction with another service, which means you might not simply report the injection on your claim. Brush up on how -- and when -- to append four common modifiers and ensure accurate injection pay.

Add Modifier 25 to Associated E/M Visit

If your pain management provider administers an unrelated injection during a standard E/M visit, remember modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Example: A patient visits your office for a follow-up for his chronic low back pain. During the evaluation, he also complains of left elbow pain, which the physician determines to be recurrent lateral epicondylitis (726.32).

The physician injects local anesthetic and steroid at the origin of the Extensor Carpi Radialis Brevis tendon which you code with 20551 (Injection[s]; single tendon origin/insertion).

Because your provider completed both a separately identifiable and significant E/M service in management of the patient's chronic low back pain and definitive procedure in treatment of the lateral epicondylitis, you can report both services. Including modifier 25 on the claim shows that the physician's services associated with the E/M service were in fact separate and significant beyond the pre- and post-injection work associated with the tendon origin injection.

Tip: Modifier 25 always links to the E/M code, not the code for the additional procedure.

Double Check Descriptors Before Using Modifier 50

It's not uncommon for providers to inject "mirror image" joints (such as both knees), during the same treatment session. That's when modifier 50 (Bilateral procedure) comes into play -- but don't automatically add it to all your injection codes.

Example: You report trigger point injections based on the total number of muscles your provider injects, not where those muscles are located. Injections of trigger points in both the right and left Piriformis muscles would not be billed as a bilateral procedure. Instead, the injections would still fall under codes 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscles) or 20553 (...3or more muscle[s]). Reporting the bilateral modifier with either of the trigger point injection codes is not compliant coding and billing.

Tip: When you do submit claims with modifier 50, such as with bilateral cervical transforaminal epidural injections, check your payments to see if the insurer has been paying you unilaterally (at 100 percent) instead of bilaterally (at 150 percent). Audits frequently reveal documentation and coding that supports a bilateral procedure that the insurer has paid unilaterally, says Joanne Schade-Boyce, RDH, MS, CPC, ACS, PCS, vice president of FairCode Associates LLC in Germantown, MD.

The insurer might incorrectly process Medicare's preferred modifier 50 method of a one-line entry with modifier 50 (such as 64479-50) and one unit of service. Private payers might require bilateral procedures to be reported on two lines with the RT (Right) and LT (Left) modifiers (64479-RT, 64479-LT) and 1 unit of service for each. It is always best to check with the payer as to their claims processing requirements for reporting bilateral procedures or services.

Support Modifier 59 With Clear Documentation

Turn to modifier 59 (Distinct procedural service) when your physician performs two distinct services on the same day for the same patient. Modifier 59 is an important NCCI-associated modifier that is often used incorrectly, experts say. For Medicare's NCCI bundling edits, its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.

Example: Your pain management specialist saw a patient in the office who has a trigger finger of her left hand and osteoarthritis in her right knee. The pain management specialist administers injections to the knee and finger to treat the conditions and help alleviate pain. You would report 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [eg, plantar "fascia"]) for the trigger finger injection and 20610 (... major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) for the knee injection. Currently, Medicare's NCCI 17.2 edits bundle 20550 as a column 2 component of 20610, the column 1  comprehensive code. Append modifier 59 to the 20550, the column 2 code to indicate the separate and distinct injection. Also link the appropriate diagnosis codes to each injection procedure -- 727.03 (Trigger finger [acquired]) and 715.16 (Osteoarthrosis, localized, primary; lower leg).