Neurosurgery Coding Alert

Report the other pain management procedure -- sometimes.

The latest version of Correct Coding Initiative (CCI) edits went into effect Oct. 1, and introduced a slew of pairings involving new Category III "T" codes for transforaminal epidural injections:

• 0228T -- Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level
• 0229T -- ... each additional level (List separately in addition to code for primary procedure)
• 0230T -- Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level
• 0231T -- ...... each additional level (List separately in addition to code for primary procedure).

"Although the primary procedures have been performed for years as Category I codes, the guidance method has been fluoroscopic or CT-guided," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "Since the efficacy and accuracy of ultrasound guidance has not been comparatively validated, Category III codes were developed for transforaminal epidural injections performed with ultrasound guidance to distinguish this from transforaminal epidural injections performed with CT or fluoroscopy."

Read on for details on how to steer clear of incorrect reporting.

Nerve Destruction Includes T Codes

CCI 16.3 classifies 0228T and 0230T as Column 2 components of nerve destruction codes ranging from 64600 (Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch) and 64612 (Chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]) to 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) and 64640 (Destruction by neurolytic agent; other peripheral nerve or branch).

The edits also confirm 0228T and 0230T as components of sympathetic nerve destruction and chemodenervation procedures (codes 64650-64681).

Details: The rationale behind these new bundling edits varies between "standards of medical/surgical practice" and "misuse of column two code with column one code." Most edits, however, carry a modifier indicator of "0," which means you cannot break the edit and report both codes during a single encounter.

New T Codes Override TPIs and Ligament Injections

The CCI edits classify new codes 0228T-0231T as the Column 1 comprehensive procedure in some instances.

Example: The new edits consider ligament/tendon and trigger point injection codes 20550-20553 as part of the Category III transforaminal injection codes (0228T- 0231T). The same holds true for joint injection codes 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) and 20610 (... major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]).

Good news: The edits have a modifier indicator of "1," which means you can report both codes under certain circumstances and with enough supporting documentation. You'll need to append one of the CCI-associated modifiers (such as modifier 59, Distinct procedural service) to the Column 2 code. The modifier unbundles the edit and allows payment for both services. Transforaminal Injections Include Ultrasound Guidance The CCI 16.3 edits also include new bundling pairs between ultrasound guidance (76XXX) and both the Category I transforaminal codes 64479 (Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level) and 64483 (... lumbar or sacral, single level) and the Category III transforaminal epidural procedures.

The three ultrasonic guidance radiology codes affected by these edits include:

• 76800 -- Ultrasound, spinal canal and contents
• 76942 -- Ultrasonic guidance for needle placement (e.g.,biopsy, aspiration, injection, localization device), imaging supervision and interpretation
• 76998 -- Ultrasonic guidance; intraoperative.

In addition, CCI 16.3 bundles the Category III codes 0228T and 0229T into Category I code 64479. The edits also bundle 0230T and 0231T into 64483.

Some of the edits carry a modifier indicator of "0," but most have a modifier indicator of "1." If the code pair in question has a "1" modifier, the edit allows a modifier to bypass the pairing when you have sufficient documentation.

Caveat: Don't add a modifier to break an edit just because it's allowed. Your provider needs to use ultrasound guidance with a completely different procedure before you can use a modifier to bypass the edits.

Watch E/M Service With Neuropsychological Tests

When you look beyond the 0228T family of codes, you'll find some edits that could be relevant to your neurosurgeon's services.

Neuropsychological testing and standard cognitive performance testing procedures (codes 96118-98125) are now bundled into many E/M codes, including new and established patient visits (codes 99201-99215).

The edits do allow a modifier to bypass the pairing when you have sufficient documentation. CCI 16.3 includes more than 19,000 new edit pairs, says Frank Cohen, MPA, MBB, of The Frank Cohen Group in Clearwater, Fla. Check the latest version at www.cms.gov to ensure you correctly report procedures.