Neurosurgery Coding Alert

Question: Our provider bills the following:

• 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) -50 (Bilateral procedure)
• 64494 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; second level [List separately in addition to code for primary procedure]) -50 (Bilateral procedure)
• 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed) -59 (Distinct procedural service) RT and 27096 -59 LT
• 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid])
• J1030 (Injection, methylprednisolone acetate, 40 mg)

Payers are denying 64493 as being redundant to 77003. How can we get 64493 paid when billing 77003? Can a modifier be added to 77003?

Tennessee Subscriber

Answer: The fluoroscopic guidance code is not reportable with the injection codes, which bundle the image guidance when fluoroscopy or CT imaging is used. The 2012 changes in CPT® bundle imaging guidance in 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed), whereas 64493 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level) and 64494 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; second level [List separately in addition to code for primary procedure]) already included fluoroscopy.

You shouldn't bill separately for 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]) when reporting these injection codes. Additionally, you should not append -59 (Distinct procedural services) with code 27096 as per 2012 NCCI edits version 18.0 because 27096 is not a component code for 64493 or +64494 while billing on the same claim, rather CCI believes it's a separate procedure. If code 27096 performed bilaterally and if you are reporting for Medicare, you should append -50 rather than RT/LT. Medicare always prefer with a single line item with modifier 50. So as per payers, you should append appropriate modifier with the usual procedure code.

Bill the more extensive procedure first on the claim to get 100% reimbursement and keep least procedures thereafter as per RVUs. So here your right method of billing should be: 64493-50, 27096-RT, 27096-LT, 64494-50, and J1030.