Neurosurgery Coding Alert

Check the diagnosis and where the needle is positioned.

When your surgeon provides epidural injections for the management of chronic pain, you’ll need to determine where your provider placed the needle and what condition your surgeon was trying to treat. Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting in Franklin, Tenn., helps you brush up on spinal anatomy basics so you can easily navigate your way to the right code for spinal epidural procedures.

Step 1: Know the Needle Destination

The term “epidural” actually is short for “epidural injection.” It’s a form of regional anesthesia that involves administering drugs through a needle or a catheter placed in the epidural space. Common terms your provider might document in the patient’s chart could include:

·         Epidural space or extradural space – The area located inside the spinal canal that is separated from the spinal cord and the surrounding CSF (cerebrospinal fluid)

·         Dura mater (Dura) – Separates the epidural space and the arachnoid membrane

·         Arachnoid mater – The area adherent to the inside of the dura that is more fragile than the dura

·         Subarachnoid space – The area inside the arachnoid space that contains CSF and the spinal cord.

Providers administer many injections to the epidural space, so you might see that term most often. Mention of a subarachnoid injection might lead you to code 62284 (Injection procedure for myelography and/or computed tomography, spinal [other than C1-C2 and posterior fossa]). An example of a disc injection code is 62292 (Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar).

References to the spinal column itself might also be made in the provider’s notes. Remember two important facts when reading documentation about the spine:

·         A vertebra protects the spinal cord. Vertebrae are cylindrically-shaped anteriorly and have a neural arches posteriorly. Thirty-three vertebrae make up the five regions of the spine (cervical, thoracic, lumbar, sacral, and coccyx).

·         An intervertebral disk is the tough elastic structure that lies between the bodies of spinal vertebrae. The disk consists of an outer annulus fibrosis enclosing an inner nucleus pulposus.

·         Epidural steroid injections (ESI) are given in the epidural space and may be either “translaminar” or “transforaminal” injections.

·         Transforaminal epidural steroid injections are administered specifically in the foraminal opening between two vertebrae in the cervical (i.e., C4-C5), thoracic (i.e., T4-T5) and lumbar (i.e., L4-L5) spinal regions and into the posterior foraminal openings in the sacral area (i.e., S2).

Remember: The regular epidural steroid injection (ESI) procedures (represented by codes 62310-62319) sometimes are referred to as “translaminar” injections. Don’t confuse these procedures with transforaminal ESI procedures (codes 64479/64480 for cervical/thoracic injections and 64483/64484 for lumbar/sacral). “The target for each of these codes is different, with the transforaminal injection specifically targeting a single nerve root and requiring image-guidance for localization and confirmation of injection,” Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Step 2: Find Clues in the Associated Diagnoses

“It’s very important to code the conditions associated with these procedures as specifically as possible,” Ellis says. “You don’t want to use the ‘low back pain’ symptom code (724.2) or something equally as general and non-specific to code every claim.”

Insurers are more carefully looking at the medical indications and necessity for performing these injections, particularly given the clinical evidence examining the benefits and limitations of these procedures.

Many of the conditions you might report have anatomic-specific diagnosis codes. For example, spinal stenosis has four possible options:

·         723.0 — Spinal stenosis in cervical region

·         724.01 — Spinal stenosis, other than cervical; thoracic region

·         724.02 — … lumbar region, without neurogenic claudication

·         724.03 — … lumbar region, with neurogenic
claudication.

Tip: “If you can’t locate the patient’s true condition in the procedure report, review the H&P (history and physical) for this information,” Ellis advises. You can also query the physician, adds Sarah Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president of the consulting firm SLG, Inc., in Raleigh, N.C. “If the clinical indication isn’t clear, the physician needs to be educated to clearly report the diagnosis, preferably using ICD-9 or ICD-10 language, in order to properly report the service and avoid an unnecessary denial,” says Przybylski.

Step 3: Add Procedure to Location for Correct Code

Once you know the injection type and anatomic location, you can narrow the potential procedure choices.

Example 1: The physician administered an epidural, but you can’t distinguish the vertebrae noted. The diagnosis is cervical spinal stenosis. After querying the physician and asking him to amend the record, you determine that the best injection code is 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). You submit 723.0 for the associated diagnosis.

Example 2: For the condition spondylolisthesis, diagnosis codes are not based on the spinal location (cervical, thoracic, lumbar, etc.) as with many other conditions but rather whether the condition is acquired (738.4) or congenital (756.12) meaning that the patient was born with the condition. Spondylolisthesis occurs when one vertebrae becomes displaced and slips over the next vertebrae down. Physicians might treat the condition with facet joint injections (64490 or 64493), transforaminal epidural steroid injections (64479 or 64483), or epidural steroid injections (62310 or 62311). “The targets of these injections are different, for the purpose of treating a specific type of symptom,” says Przybylski.

Step 4: Pay Attention to Editing Bundles

The Correct Coding Initiative (CCI) lists many edits related to ESI procedures.

For example, the edits bundle code 64479 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, single level) into 62310 as mutually exclusive, i.e., rarely to never performed together. The CCI table also bundles 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level) as a column 2 code into the column one code 62311 (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; lumbar or sacral [caudal]). Therefore, for Medicare and other payers who observe the CCI edits, you cannot bill these codes together when the injections are performed to the same spinal area during the same patient encounter.

Scenario: If the physician performs an L4-L5 interlaminar ESI (billed with 62311) with fluoscopic guidance and a transforaminal ESI (64483) at the L4-L5 foraminal opening, you should only report 62311. However, if the physician performs a caudal ESI (62311) at the sacral hiatus and the transforaminal ESI (64483) at L1-L2, you can likely report both injections since the two injections are at different (distant) anatomic sites. Append modifier 59 (Distinct procedural service) to 64483 and list it as the second procedure code on the claim.