Question: Is there an actual procedure code for a hardware injection? I bill 64999 and submit with the chart notes, then appeal the denial with a letter explaining the procedure. I currently have an insurance company that denied the appeal and is requesting a different CPT® code for a claim correction.
Part of my letter explaining the procedure states, “spinal fusion hardware inflaming the surrounding area causing the patient’s pain level to be a 6/10. The provider injected Celestone an anti-inflammatory medication around the distal screws of the C1-2 level hardware fusion.”
The provider is not injecting the epidural space or the nerves but the space surrounding the distal screws. How should we report this?
In the appeal, you could include a statement regarding why you’re using the unlisted code. An example would be, “The Instructions for Use of CPT® Codebook clearly state – ‘Do not select a CPT® code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.’ I have found that no CPT® code exists for _____________, therefore I am submitting 64999 Unlisted procedure, nervous system for my services provided to your insured.”
It would be helpful to discuss the situation with a representative of the insurer before refiling the claim.
Alabama Subscriber
Answer: You’re wise to submit 64999 (Unlisted procedure, nervous system) with documentation and to be prepared for an appeal since it can be difficult to gain reimbursement for “unlisted” procedures.
Also note: It’s somewhat unusual for a provider to inject a steroid solely during the hardware block. Instead, a short duration local anesthetic such as Lidociane typically is injected so the physician can determine if the particular retained vertebral screw is the source of the patient’s post-fusion pain. The hardware typically doesn’t cause “inflammation” but the screw may cause pain due to placement near the spinal nerve.