Neurosurgery Coding Alert

Physicians billing facet joint injections (64470-64476) must observe strict utilization and medical-necessity guidelines. Careful documentation and complete ICD-9 coding will ensure that claims receive the reimbursement they deserve. In addition, properly reporting fluoroscopic guidance will increase both coding accuracy and your bottom line.

Most payers will reimburse a maximum of three facet joint injections per session, each at a different spinal level. In addition, payers typically limit the total number of injections the physician may bill for the same patient within a given time frame. For example, Aetna U.S. Healthcare (a large private payer) instructs physicians, "Facet joint injections should be limited to a maximum of three sets of injections over a 12-month period." Aetna defines one "set of injections" as treatment of up to three anatomic sites during a single session. Either individual spinal levels or the left and right sides of a single level count as a separate anatomic site (that is, a bilateral injection counts as two anatomic sites).

Medicare carriers observe similar restrictions. Empire Medicare, the Part B provider for New Jersey, instructs in its local medical review policies (LMRP) for facet joint injections, "Claims for an unusually large number of facet nerve blocks will be denied as not ... necessary in the absence of supportive documentation," and, more explicitly, "Provision of more than three levels of facet joint blocks on the same day is not considered medically necessary."

Note, however, that the first statement does leave open the possibility of payment for more than three injections per session under the appropriate circumstances. Specifically, the LMRP seems to indicate that if the physician targets the facet nerve (that is, the median branch nerve), rather than the facet joint and he or she provides appropriate documentation the payer may allow the claim. But not all payers make the distinction between facet nerve and facet joint injections. Check with your payer for its guidelines prior to billing

Note: For information on injection of facet nerve versus facet joint, see Neurosurgery Coding Alert, December 2002.

Generally, payers will reimburse for facet joint injections when the patient has "chronic pain." Be aware, however, that the definition of chronic (as opposed to "acute") pain differs from payer to payer, says Patricia Bukauskas, CPC, a pain management coding and reimbursement specialist and CEO of TB Consulting, a coding and reimbursement company in Aliquippa, Pa. For instance, Empire says, "Chronic pain is defined as pain which has been present for six months or more," while Aetna requires only three months to pass.

Regardless of payer, the physician must document a history of pain for the minimum specified time. Empire's LMRP makes this point very clear, stating, "The indications for any nerve block appropriately begin with a sequential diagnostic evaluation of chronic pain." A history and physical explaining the type, severity, exacerbating factors, and medical and psychological disorders related to the pain, the policy continues, "is assumed."

Some payers will allow "suspicion of facet joint pain" as a valid indication for facet joint injection, Bukauskas says. In these cases, the physician must nonetheless demonstrate that the patient does not have radiculopathy (as ruled out by physical/electrophysiologic examination), and documentation should indicate how the provider arrived at the suspected diagnosis.

In all cases, the physician should document the preoperative evaluation that led to the suspicion of the presence of facet joint pathology, as well as postoperative conclusions, Bukauskas says. "Medicare now wants the documentation for these injections to resemble that of an operative report, including pre- and post-op diagnoses and conclusions," she says.

As a rule, payers accept diagnoses only from the 720-724 (Dorsopathies) portion of ICD-9 for facet joint injections, but not all payers accept the same particular codes within this range. For example, although most payers accept 721.3 (Lumbosacral spondylosis without myelopathy), not all will allow 724.2 (Lumbago; low back pain; low back syndrome) or 724.8 (Other symptoms referable to back) without further explanation. To be sure that you are linking an appropriate diagnosis to the injections reported, ask your insurer for a list of appropriate ICD-9 codes.

In all cases, you must report the diagnosis(es) to the highest level of specificity (e.g., 724.1, Pain in thoracic spine, versus 724.0x, Spinal stenosis, other than cervical). And of course, as the Empire LMRP notes, "It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be present for the procedure to be paid."

If the physician provides facet joint injections for a diagnosis the payer does not normally cover, he or she must thoroughly document the rationale for providing the service. Such claims should include a statement such as "Medical necessity documented in the patient's medical record" on the comments line of the electronic claim form. Or, still better, send a paper claim with all documentation attached.

When using fluoroscopic guidance to place the needle prior to injection, don't forget to report 76005 (Fluoro-scopic 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), says Jan Rasmussen, CPC, president of Professional Coding Solutions, an Eau Claire, Wis.-based consulting firm. This code more accurately describes guidance during injection than 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]). In the past, some payers continued to recommend 76000, but most should have updated their guidelines by now. If the physician administers the injection in the hospital, he or she must add modifier -26 (Professional component) to 76005 if the pain physician performed the fluoroscopy.

Note: For complete information on fluoroscopy, see Neurosurgery Coding Alert, November 2002.