Orthopedic Coding Alert

Stop denials now by learning how to code injections properly

If your orthopedic surgeons administer facet injections regularly, pay attention to these key areas to help make sure your claims aren't denied.

Verify That the Diagnosis Is Appropriate

Physicians use facet injections to help relieve the pain of many common -quot; and a few less common -quot; conditions. These can include spondylosis (721.x, Spondylosis and allied disorders), spondylolisthesis (738.4 or 756.12), facet syndrome (724.8, Other symptoms referable to back), and injury to the patient's median branch (955.1, Injury to peripheral nerve[s] of shoulder girdle and upper limb; median nerve), says Trish Bukauskas-Vollmer, CPC, MPC, owner of TB Consulting in Myrtle Beach, S.C.
 
Diagnosis checkpoint: Remember that approved diagnoses vary by carrier, says Myriam Nieves, CPC, ACS-PM, owner of Precision Medical Systems in Ft. Lauderdale, Fla.
 
-I recommend that coders familiarize themselves with their carrier's LCD [local coverage determination], since it can vary a great deal,- she says.
 
For example, Tennessee's and Idaho's Medicare carriers only list three acceptable diagnoses for facet injections: 721.1 (Cervical spondylosis with myelopathy), 721.2 (Thoracic spondylosis without myelopathy), and 721.3 (Lumbosacral spondylosis without myelopathy).
 
Other states may publish a wider range of accept-able diagnoses.
 
-The most common diagnoses I see for facet injections are lumbago (724.2) and cervicalgia (723.1),- Nieves says. -But, once again, these are only approved by certain carriers.-
 
Note: No matter what diagnoses your carrier accepts, remember to code according to the patient's record, not just to fit the list of covered diagnoses.

Base Your Codes on Levels

When you code the facet injection, you should select from four choices:
 
- 64470 -quot; Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level
 
- +64472 -quot; - cervical or thoracic, each additional level (list separately in addition to code for primary procedure)

- 64475 -quot; - lumbar or sacral, single level
 
- +64476 -quot; - lumbar or sacral, each additional level (list separately in addition to code for primary procedure).   
 
You should choose the correct code based on the location the surgeon injects and whether you-re reporting a first-level or additional injection.
 
The challenge: Coders tell us that they find it difficult to code facet joint injections because they have trouble figuring out how many units to report.
 
Here's the scoop: If the surgeon administers more than one injection at the same spinal level and on the same side of the spine, you should report only a single unit of service to most payers. The descriptor for 64470 specifically notes -single level- and not -per injection,- so you should never report two units of 64470 for several injections to one side of a spinal level.
 
Remember: Although the facet joint injection descriptors specify spinal -levels,- the surgeon actually targets facet joint injections at the space between vertebrae, not at the vertebrae themselves. Therefore, if the surgeon documents, for instance, -Facet joint injection at C4/C5,- this represents a single injection to the space between the fourth and fifth cervical vertebrae, not two separate injections at the fourth and the fifth vertebrae.

Follow Policies for Bilateral Reporting

Your key to successful reimbursement for bilateral facet injections is to learn how each carrier wants the procedure billed, Nieves says.
 
Example: Florida's Medicare carrier, United Healthcare, and several state Department of Labor carriers want you to report bilateral injections on one line with modifier 50 (Bilateral procedure) appended. Other carriers will accept injections reported on separate lines, with modifier 50 appended on the second line.
 
Your carrier's LCD should clearly outline how to correctly report bilateral injections.
 
Example: New York Empire's policy states, -If a particular level is injected bilaterally, the correct number of services remains as one, since only one level was injected. It would be appropriate to use the 50 modifier in the instance that a level was injected bilaterally. For example, if three lumbar facet joints were injected bilaterally, the correct coding would be one service of 64475-50 and two services of 64476-50.-
 
Fee reminder: If you bill bilateral facet injections on a single line with modifier 50, remember to double your charge. For example, a physician who charges $400 for 64475 and $200 for 64476 when performing bilateral injections on two levels would report the procedure as:
 
64475-50 $800
 
64476-50 $400.
 
-This is one of the most common mistakes with facet injection coding, although billing software can be programmed to automatically double the charge,- Nieves says. -Keeping a spreadsheet of how each insurance company wants the bilateral procedures billed can help a great deal and will help keep your practice from raising red flags.-