Orthopedic Coding Alert

The next time you code an epidural steroid injection (ESI), take a second look at your claim. If you miss a legitimate chance to report fluoroscopy code 77003, you could be losing $55 to $95, depending on where your office is located.

Here's a comprehensive look at coding ESI encounters so you can be sure you-re getting every dime you deserve.

The surgeon likely will choose a translaminar epidural approach, placing the medicine inside the epidural space. Your CPT choices for this ESI include the following:

- 62310 -- Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

- 62311 -- -lumbar, sacral (caudal).

Medicare assigns 62310-62311 bilateral status indicator "0," which means Medicare will reimburse you for only a single injection even if the surgeon administers bilateral injections.

Pay attention: Be careful not to confuse single injection ESI codes 62310-62311 with the following codes for continuous infusion or intermittent bolus:

- 62318 -- Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

- 62319 -- - lumbar, sacral (caudal).

In some cases, the physician may choose a transforaminal approach. This approach places the medicine outside the epidural space and tracks it into the epidural space at specific levels. For this approach, you-d use a different set of codes, as follows:

- 64479 -- Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level

- +64480 -- - cervical or thoracic, each additional level (list separately in addition to code for primary procedure)

- 64483 -- - lumbar or sacral, single level

- +64484 -- - lumbar or sacral, each additional level (list separately in addition to code for primary procedure).

Add-on rules: You should report 64479 and 64483 as the primary codes for the first transforaminal injection to the cervical/thoracic or lumbar/sacral levels, respectively. Use add-on codes 64480 and 64484 for each additional injection at the cervical/thoracic or lumbar/sacral levels, respectively.

Example: The physician administers two lumbar transforaminal ESIs at different levels. You should report 64483 for the first lumbar injection and 64484 for the additional level injection.

Bilateral tip: Note that the Medicare physician fee schedule assigns 64479-64484 bilateral status indicator "1." That means that you may report bilateral services, and Medicare will process payment for them. Depending on your payer's preference, you may report bilateral transforaminal injections with modifier 50 (Bilateral procedure) or anatomical modifiers LT (Left side) and RT (Right side).

Increasingly, surgeons are using imaging guidance to verify precise needle placement for the ESI. You may report fluoroscopic guidance separately with 77003 (Fluoroscopic 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). Medicare reimburses roughly $55 to $95 for this code, depending on geographic location, according to the fee schedule.

Watch for: The surgeon needs to document that he used fluoroscopic guidance for the procedure, says Stacy Gregory, RCC, CPC, owner of Gregory Medical Consulting Services in Tacoma, Wash.

Don't get confused: A note with 77003 states that codes such as 62310-62319 include "injection of contrast during fluoroscopic guidance and localization." But contrast injection during fluoroscopic guidance and the fluoroscopic guidance itself are not the same. Therefore this statement in no way prevents you from reporting 77003 with ESI codes.

Bonus tip: If you aren't familiar with the 70000 section of the CPT manual, you may be tempted to report an epidurogram (72275, Epidurography, radiological supervision and interpretation) for epidural steroid injection guidance instead of the appropriate fluoroscopy code (77003). An epidurogram is a diagnostic tool, which means documentation should support medical necessity for the test and offer a description of the findings. A radio-logist is far more likely to perform an epidurogram than your surgeon is.

Matching your ESI and fluoro codes to the proper ICD-9 code is essential for proving medical necessity. Some payers spell out the diagnoses that indicate ESI medical necessity.

Example: Blue Cross and Blue Shield of Florida's policy states that you meet medical necessity requirements when "two or more weeks of conservative measures (e.g., rest/limited activity, physical therapy, or oral medications) have failed," and the patient has one of several conditions (such as spinal stenosis). The payer's Web site also includes a long list of ICD-9 codes indicating medical necessity (http://mcgs.bcbsfl.com).

The following list shows some of the conditions matched to possible ICD-9 codes indicated by the policy:

- intervertebral disc disease with or without myelo-pathy (722.X, Intervertebral disc disorders)

- spinal stenosis (723.0, Spinal stenosis in cervical region; 724.0X, Spinal stenosis, other than cervical)

- postlaminectomy syndrome/failed back syndrome (722.8X, Postlaminectomy syndrome)

- radiculitis (723.4, Brachial neuritis or radiculitis, NOS; 724.4, Thoracic or lumbosacral neuritis or radicu-litis, unspecified).

Remember: You should never choose a diagnosis based solely on what the payer covers. Because you must base your ICD-9 code on the patient's record, reviewing payer policies with the surgeon may help him to understand which diagnoses the payer covers and the importance of proper documentation.

In addition to the procedure and diagnosis, you may report the steroid used if your practice bears the cost.

Drugs the surgeon may use include the following, says Myriam Nieves, CPC, ACS-PM, owner of Precision Medical Systems in Ft. Lauderdale, Fla.:

- Kenalog (J3301, Injection, triamcinolone acetonide, per 10 mg)

- Celestone Soluspan (J0702, Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg)

- Depo-Medrol (J1020-J1040, Injection, methylprednisolone acetate -)

- Aristopan (J3303, Injection, triamcinolone hexa-cetonide, per 5 mg).

Now that you-ve read about ESI CPT, ICD-9 and HCPCS coding, decide how you would code the following ESI scenario, and then check your answer below.

Example: Your physician administers a lumbar ESI for a patient with a herniated lumbar disc without myelopathy. He uses fluoroscopy to guide needle placement and injects Depo-Medrol, 40 mg.

Solution: You should report the single lumbar injection with 62311 and the fluoroscopy with 77003. Report the Depo-Medrol with J1030 (Injection, methylprednisolone acetate, 40 mg).

For the diagnosis, you should report 722.10 (Lumbar intervertebral disc without myelopathy).

Note: Turn to the next page for an ESI coding tool.