Neurosurgery Coding Alert

The above codes, as well as the term "facet joint injection," actually describe two distinct but related procedures, says Patricia Bukauskas, CPC, a pain management coding and reimbursement specialist and CEO of TB Consulting, a coding and reimbursement company in Aliquippa, Pa. The first type of injection, often referred to as an intra-articular block, involves injecting an anesthetic and/or steroid to denervate the paravertebral facet joint (the bony surface between vertebrae). In the second procedure, the physician targets the facet joint nerve, correctly called the median branch nerve.

Either type of injection can be diagnostic (the most common use) or therapeutic. As a diagnostic tool, the physician uses the injections to document or confirm diagnoses of posterior elemental biomechanical back pain caused by structural abnormalities. The physician administers the injection to block the pain. The patient then performs the same activities that usually aggravate his or her back pain, and the physician records any effects. The absence of lower back pain after the injections suggests that the facet joint(s) is the source of the problem.

Therapeutic injections provide temporary pain relief to facilitate other types of treatment, such as physical therapy. Generally, physicians administer such injections only when pain is neither disc-related nor radicular, i.e., related to nerve roots.

Note: You should report phenol (or other neurolytic) destruction of the paravertebral facet joint nerve with 64622-64627. These injections should not be confused with the nerve block, which has only a temporary effect.

Report the initial injection using either 64470 (cervical or thoracic) or 64475 (lumbar or sacral) as appropriate to location, says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM Program Coordinator at Clarkson College in Omaha, Neb. Report each additional level with a single unit of either +64472 or +64476, again as appropriate to location, i.e., +64472 must accompany 64470, and +64476 must accompany 64475. You may report multiple units of +64472/+64476 per session, as supported by documentation, but you may report only a single unit of 64470/64475 per session.

Note that the physician targets these injections at the space between vertebrae, not at the vertebrae themselves. Therefore, if the physician documents "Facet joint injection at C3/C4," this represents a single injection to the interspace between the third and forth cervical vertebrae, not two separate injections at the third and fourth cervical vertebrae, respectively, Bucknam says. Therefore, the correct coding is 64470. In a second example, the physician administers a single injection to each of the L1/L2, L2/L3 and L3/L4 interspaces. In this case, the appropriate coding is 64475, +64476 x 2.

Although your documentation and diagnoses may vary, CPT coding is identical whether the injection targets the intra-articular space or the median nerve or for diagnostic or therapeutic reasons, Bukauskas advises.

Most carriers bundle multiple injections on the same level. For instance, National Heritage Insurance Company, the Medicare Part B carrier for California, Maine, Massachusetts, New Hampshire and Vermont, specifies in its local medical review policy, "[a facet joint injection] is considered a single procedure whether or not it is performed as a single injection (intra-articular route) or more peripherally and blocking the articular [i.e., median branch] nerves with two injections."

For example, a physician must administer two injections to block the median branch nerve inside the joint because one branch of the nerve sits at the top of the facet joint and a second branch sits at the bottom. Some doctors mistakenly believe that because they must administer two injections, they may bill two separate codes. This is not the case: The descriptor for 64470-+64476 specifically notes single level, not "per injection."

Two injections for a nerve block at T1/T2 and two more at T2/T3 equals only two levels, although the physician administered a total of four injections. Therefore, the appropriate coding is 64470, +64472.

Do: Use modifier -50 to specify bilateral injections. Bilateral injections (i.e., on both the left and right side) at a single level differ from multiple injections at the same level on one side. Specifically, the 2002 National Physician Fee Schedule assigns a bilateral status indicator of "1" to 64470-64476, thereby allowing providers to append modifier -50 (Bilateral procedure) and receive a 150 percent payment adjustment for bilateral injections.

For example, the physician injects the left and right side at T7/T8 and T8/T9 and the left side only at T9/T10. In this case, report 64470-50 (for the initial bilateral injection at T7/T8), +64472-50 (for the additional bilateral injection at T8/T9) and +64472 (for the unilateral injection at T9/T10). If the physician provided bilateral injections at all levels, proper coding is 64470-50, +64472-50 x 2.

In a second example, the physician provides injections bilaterally at T11/T12, T12/L1 and L1/L2. In this case, report 64470-50 (for the initial bilateral injection at T11/T12), 64475-50 (for the initial bilateral injection at T12/L1) and +64476-50 (for the additional bilateral injection at L1/L2). Note that in this case the payer may reduce payment for 64475, treating it as an "additional level" code rather than an initial injection.

Commercial insurers often require two lines for modifier -50 claims, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a physician reimbursement consulting firm in Lakewood, N.J., and vice president of the Coding and Reimbursement Network. In such a case, the coding for the above example is 64470, 64470-50, 64475, 64475-50, +64476, +64476-50. Ask your insurers for their policy on appropriate listing of modifier -50 claims.

Do not assume that insurers will automatically increase your fee because you have appended modifier -50. Some computer systems may not automatically recognize modifier -50. Therefore, you should remember to manually increase the fee to 150 percent of the usual amount.

Don't: Append modifier -51 to add-on codes. Do not append modifier -51 (Multiple procedures) to +64472 or +64476. These are add-on codes, for which carriers have already reduced fees to reflect their status as "additional" procedures. Appending modifier -51 may prompt your payer to reduce the fee inadvertently (and incorrectly) by an additional 50 percent.

Next Month: ICD-9 coding tips, proving medical necessity, and billing for fluoroscopic guidance with facet joint injections.