Neurology & Pain Management Coding Alert

It pays to reconsider run-of-the-mill epidural steroid injections (ESIs). If your neurologist uses fluoroscopy in addition to an ESI, you-ll want to be sure you code for it. Otherwise, you risk losing $55 to $95 in additional payouts.

Here's a thorough look at coding ESI encounters so you can be sure you-re getting every dime you deserve.

The neurologist likely will choose an interlaminar epidural approach, placing the medicine inside the epidural space.

"As long as the needle is positioned in the epidural or subarachnoid space with the needle going -straight- in between the lamina," then you should choose from the following codes, says Julee Shiley, CPC, CCS-P, CMC, in Raleigh, N.C.:

- 62310 -- Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

- 62311 -- - lumbar, sacral (caudal).

Pay attention: Be careful not to confuse single injection codes 62310-62311 with the following continuous infusion or intermittent bolus codes:

- 62318 -- Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

- 62319 -- - lumbar, sacral (caudal).

If the neurologist performs an injection at an angle into the nerve root area outside the epidural space, this is a transforaminal (through the foramen) injection, says Shiley.

With this type of epidural, the neurologist injects the medication into the intervertebral foramen "bathing" a specific spinal nerve as it exits the spinal cord. For this approach, you-d use a different set of codes, as follows:

- 64479 -- Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level

- +64480 -- - cervical or thoracic, each additional level (list separately in addition to code for primary procedure)

- 64483 -- - lumbar or sacral, single level

- +64484 -- - lumbar or sacral, each additional level (list separately in addition to code for primary procedure).

Add-on rules: You should report 64479 and 64483 as the primary codes for the first transforaminal injection to the cervical/thoracic or lumbar/sacral levels, respectively. Use add-on codes 64480 and 64484 for each additional injection at the cervical/thoracic or lumbar/sacral levels, respectively.

Example: The neurologist administers transforaminal ESIs at the right L4-L5 and L5-S1 intervertebral spaces, two different levels. You should report 64483 for the first lumbar injection and 64484 for the additional level injection.

Increasingly, neurologists are using imaging guidance to verify precise needle placement for the ESI. You may report fluoroscopic guidance separately with 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).

The Medicare Physician Fee Schedule indicates a reimbursement range from roughly $55 to $95, depending on where your office is.

Watch for: The physician needs to document that he used fluoroscopic guidance for the procedure, says Stacy Gregory, RCC, CPC, owner of Gregory Medical Consulting Services in Tacoma, Wash.
Don't get confused: The parenthetical note following 77003 states that codes such as 62310-62319 include "injection of contrast during fluoroscopic guidance and localization." This means that a provider cannot separately bill for the injection of contrast if performed during fluoroscopic guidance, but the note does not restrict a provider from reporting 77003 with these epidural injection codes.

Matching your ESI and fluoro codes to the proper ICD-9 code is essential for proving medical necessity. Many payers, including most Medicare carriers and some commercial payers, have coverage policies that spell out the diagnoses that indicate ESI medical necessity.

Example: Aetna states that providers should administer therapeutic selective transforaminal epidural injections as part of a comprehensive pain management program. Administration of more than three such injections per six months is subject to medical necessity review. They are generally medically necessary when used for "identifying the etiology of pain in persons with symptoms suggestive of chronic radiculopathy, where the diagnosis remains uncertain after standard evaluation (neurologic examination, radiological and neurodiagnostic studies)" (http://www.aetna.com/cpb/medical/data/700_799/0722.html).

The following list shows some of the conditions and corresponding ICD-9 codes indicated to support medical necessity for epidural injections by many payer policies:

- 722.0-722.2 -- Displacement of intervertebral disc without myelopathy-

- 722.4-722.6 -- Degeneration of intervertebral disc -

- 722.8X -- Postlaminectomy syndrome -

- 723.0, 724.0x -- Spinal stenosis -

- 723.4, 724.4 -- Neuritis or radiculitis -

Remember: You must base your ICD-9 code on the documentation. You should never choose a code based solely on what the payer covers.

In addition to the procedure and diagnosis, you may report the steroid used if your practice bears the cost of an ESI performed in the neurologist's office.

Drugs the neurologist may use include the following, says Myriam Nieves, CPC, ACS-PM, owner of Precision Medical Systems in Ft. Lauderdale, Fla.:

- Kenalog (J3301, Injection, triamcinolone acetonide, per 10 mg)

- Celestone Soluspan (J0702, Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg)

- Depo-Medrol (J1020-J1040, Injection, methylprednisolone acetate -)

- Aristopan (J3303, Injection, triamcinolone hexacetonide, per 5 mg).

Now that you-ve read about ESI CPT, ICD-9 and HCPCS coding, decide how you would code the following ESI scenario, and then check your answer below to see how you measure up.

Example: Your neurologist administers an L3-L4 interlaminar lumbar ESI for a patient with a herniated lumbar disc. He uses fluoroscopy to guide needle placement, and the drug injected is Depo-Medrol, 40 mg.

Solution: You should report the single lumbar interlaminar injection with 62311 and the fluoroscopy with 77003. Report the Depo-Medrol with J1030 (Injection, methylprednisolone acetate, 40 mg). For the diagnosis, you should report 722.10 (Displacement of lumbar intervertebral disc without myelopathy).