Neurology & Pain Management Coding Alert

Latest edits also caution you about reporting injections with fluoro.

You can now sometimes report trigger point injections administered during the same treatment session as an epidural, but still be cautious when reporting injections with fluoroscopic guidance. Get the lowdown on these and other pertinent Correct Coding Initiative edits (version 18.2), effective July 1.

Welcome Back TPI Reporting With Epi Injections - Sometimes

Although sorting through all the CCI edits can be daunting, don't overlook the "deleted edits" section. With CCI 18.2 in effect, you'll now be able to report trigger point injections (TPIs) with some injections that were previously labelled "no go."

Earlier edits listed the TPI codes as the Column 1/comprehensive procedure in each pair. That meant you would report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553 (... single or multiple trigger point[s], 3 or more muscle[s]) instead of the other injection from the pair. Now, when you have sufficient documentation to support both services, CCI 18.2 states you can report TPI along with single-shot or continuous epidurals:

• 62310 -- Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic
• 62311 -- ... lumbar or sacral (caudal)
• 62318 -- Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic
• 62319 -- ... lumbar or sacral (caudal).

Explanation: "The edits that were deleted for the trigger point injection codes and the epidural injections, had the epidural codes (i.e., 6210-62319) as the 'component' Column 2 code with the trigger point injection codes as the 'comprehensive' Column 1 code," explains Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. "Epidural injections or infusions are not performed as anesthesia for trigger point injections."  

Before being able to code for both the TPI and epidural during the same encounter, verify that both services are merited -- and separate.

Example: Your provider administers a lumbar epidural injection to alleviate a patient's pain from a lumbar herniated disc (62311). The patient also has pain in her cervical /upper thoracic muscle trigger points, so provider also injects the trigger points during the same session (20552). The lumbar epidural is used to treat the disc herniation, not provide "anesthesia" for the trigger point injections " so you can submit codes for both services.

The same mindset applies to other edits that reversed pairing TPIs with a few other injections:

• 64408 -- Injection, anesthetic agent; vagus nerve
• 64410 -- ... phrenic nerve
• 64435 -- ... paracervical (uterine) nerve
• 64455 -- Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton's neuroma).

Steer Clear of Fluoroscopy With 64480, 64484

Non-mutually exclusive edits represent procedures CMS has determined physicians should not bill together because one service inherently includes the other. These are also known as bundled services, or comprehensive/component edits.

According to CCI 18.2, you cannot report certain fluoroscopy or CT guidance procedures in conjunction with injection codes 64480 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, each additional level [List separately in addition to code for primary procedure]) and 64484 (... lumbar or sacral, each additional level [List separately in addition to code for primary procedure]). The edit is no surprise, considering that the injection descriptors include the verbiage "with imaging guidance."

Fluoroscopy and CT codes affected by these edits include:

• 76000 -- Fluoroscopy (separate procedure), up to 1 hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy)
• 76001 -- Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy)
• 77002 -- Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
• 77003 -- Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)
• 77012 -- Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation.

Side-step if appropriate: Each of the edits carries a modifier indicator of "1," meaning that you might be able to report -- and be paid for -- both codes under certain circumstances. If so, you would append a modifier (such as modifier 59, Distinct procedural service) to the guidance code to indicate a separate service. For example, your pain management provider might use the fluoroscopic guidance to perform a different procedure, i.e. an elbow joint injection, as well as the transforaminal epidural injection. Then it would be appropriate to use the modifier to bypass the bundling edit.

Resource: CCI 18.2 introduced a total of 2,399 additional edits and 88 deletions, according to an analysis from Frank Cohen of the Frank Cohen Group in Clearwater, Fla. For a complete look at the edits, visit the CCI page on the CMS website.