Neurosurgery Coding Alert

Here’s How Coding Affected by ‘Imaging Guidance’ Addition

The codes that will change in 2023 are 64415-64417 and 64445-64448, which all share this common start to their descriptors: Injection(s), anesthetic agent(s) and/or steroid ….

“Practices have used these codes for many years. They bill ultrasound separately for imaging guidance, and this will be a major change,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida.

In fact, “the specialty societies stated that CPT^® codes 64415, 64416, 64417, 64446, 66447, and 64448 were reported with the imaging code CPT^® code 76942 [Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation] more than 50 percent of the time,” the 2023 MPFS proposed rule states (www.federalregister.gov/d/2022-14562/p-506).

What’s changing: CPT^® 2023 will add “including imaging guidance, when performed” to the descriptors for these codes. That means you will no longer report ultrasound (such as 76942) or other types of imaging guidance separately when the provider uses that guidance to perform services you report using 64415-64417 and 64445-64448. The examples below help demonstrate how these descriptor revisions will affect your coding.

Old way: For a 2022 date of service (DOS), suppose a surgeon at a facility uses ultrasound guidance to perform a brachial plexus anesthetic injection for post-op pain management. You report the injection and guidance using these codes:

• Injection: Report 64415 (Injection(s), anesthetic agent(s) and/or steroid; brachial plexus).
• Guidance: Report 76942 with modifier 26 (Professional component).

Refresh Your Knowledge of Somatic Nerves

Codes 64415-64417 and 64445-64448 are in the CPT^® range “Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Procedures on the Somatic Nerves.” The somatic nerves are part of the peripheral nervous system, meaning the part of the nervous system that does not include the brain and spinal cord.

The somatic nervous system allows movement and control of muscles throughout the body. It also feeds information from the senses of smell, sound, taste, and touch to the brain.

Upper body: Codes 64415 and 64416 are specific to the brachial plexus, a network of nerves in the shoulder that carries movement and sensory signals from the spinal cord to the arms and hands. Code 64417 applies to axillary nerve services. The axillary nerve, also known as the circumflex nerve, starts in the neck at the brachial plexus and extends to the shoulder. The nerve causes movement and sensation in the shoulder and the back of the upper arm, supplying the deltoid muscle and overlying skin.

Lower body: Codes 64445-64446 represent services for the sciatic nerve, which branches from the lower back through the hips and buttocks and down each leg. Codes 64447-64448 reference the femoral nerve, which is in the pelvis and also goes down the front of the leg.

New way: Consider the same example as above, but for a 2023 DOS. You will report only one procedure code:

• Injection and guidance: Report 64415 (… brachial plexus, including imaging guidance, when performed).

Bonus tip: The 2023 descriptors state the codes include “imaging guidance, when performed,” so you will report the injection code regardless of whether the provider uses imaging guidance. You should not append a reduced service modifier such as 52 (Reduced services) to indicate the provider did not use imaging guidance, since the injection may be performed without image guidance.

Look Ahead to Payment Changes

Because the injection codes will include imaging guidance time and services, the 2023 proposed MPFS includes potential updates to the work relative value units (RVUs) for these codes. “This is a huge change that will affect payments,” says Dennis.

You can expect all the injection services with imaging guidance to have a change in work RVUs in 2023. The table compares the proposed 2023 injection code work RVUs to the 2022 work RVUs for the injection codes, which now include image guidance including ultrasound guidance (76942), when performed. Remember that work RVUs are part of the basic formula to determine the MPFS payment amount:

(Work RVUs + practice expense RVUs + malpractice RVUs) x MPFS conversion factor.

Geographic location also will affect final payment. The final work RVUs for these codes may differ, so be sure to check the final MPFS rule when it is available.