Outpatient Facility Coding Alert

Start with a clear understanding of anatomy.

When it’s time to report an epidural for pain management, you’ll need to know exactly where the provider places the needle to accurately code these services. Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting in Franklin, Tenn., shares her insights on spinal anatomy so you can follow the placement and diagnosis to the correct procedure code.

Step 1: Know the Needle Destination

The term "epidural" actually is short for "epidural anesthesia." It’s a form of regional anesthesia that involves administering drugs through a needle or a catheter placed in the epidural space. Common terms your provider might document in the patient’s chart could include:

Epidural space or extradural space -- The area located inside the spinal canal that is separated from the spinal cord and the surrounding CSF (cerebrospinal fluid)

Dura mater (Dura) -- Separates the epidural space and the arachnoid membrane

Arachnoid mater -- The area adherent to the inside of the dura that is more fragile than the dura

Subarachnoid space -- The area inside the arachnoid space that contains CSF and the spinal cord.

Providers administer many injections to the epidural space, so you might see that term most often. Mention of a subarachnoid injection might lead you to code 62280 (Injection/infusion of neurolytic substance [e.g., alcohol, phenol, iced saline solutions], with or without other therapeutic substance; subarachnoid). An example of a dural injection code is 62292 (Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar).

References to the spinal column itself might also be made in the provider’s notes. Remember two important facts when reading documentation about the spine:

A vertebra protects the spinal cord. Vertebrae are cylindrically-shaped anteriorly and have a neural arch posteriorly. Thirty-three vertebrae make up the five regions of the spine (cervical, thoracic, lumbar, sacral, and coccyx).

An intervertebral disk is the tough elastic structure that lies between the bodies of spinal vertebrae. The disk consists of an outer annulus fibrosis enclosing an inner nucleus pulposus.

Epidural steroid injections (ESI) are given in the epidural space and are also referred to as "translaminar" injections.

Transforaminal epidural steroid injections are administered in the foramen of the disc, which is closer to the spinal cord.

Remember: The regular epidural steroid injection (ESI) procedures (represented by codes 62310-62319) sometimes are referred to as "translaminar" injections. Don’t confuse these procedures with transforaminal ESI procedures (codes 64479/64480 for cervical/thoracic injections and 64483/64484 for lumbar/sacral).

Step 2: Find Clues in the Associated Diagnoses

"It’s very important to code the conditions associated with these procedures as specifically as possible," Ellis says. "You don’t want to use the ‘low back pain’ symptom code (724.2) or something equally as general and non-specific to code every claim."

Many of the conditions you might report have anatomic-specific diagnosis codes. For example, spinal stenosis has four possible options:

723.0 -- Spinal stenosis in cervical region

724.01 -- Spinal stenosis, other than cervical; thoracic region

724.02 -- … lumbar region, without neurogenic claudication

724.03 -- … lumbar region, with neurogenic
claudication.

Tip: "If you can’t locate the patient’s true condition in the procedure report, review the H&P (history and physical) for this information," Ellis advises. You can also query the physician, adds Sarah Goodman, MBA, CHCAF, CPC-H, CCP, FCS, president of the consulting firm SLG, Inc., in Raleigh, N.C.

Step 3: Add Procedure to Location for Correct Code

Once you know the injection type and anatomic location, you can narrow the potential procedure choices.

Example 1: The physician administered a subarachnoid epidural, but you can’t distinguish the vertebrae noted. The diagnosis is cervical spinal stenosis. You would report 62310 (Epidural steroid 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) for the injection, and 723.0 for the associated diagnosis.

Example 2: For the condition spondylolisthesis, diagnosis codes are based on whether the condition is acquired (738.4) or congenital (756.12) meaning that the patient was born with the condition rather than based on spinal location (lumbar, cervical, etc.). Spondylolisthesis occurs when one vertebrae becomes displaced and slips over the next vertebrae down. Physicians might treat the condition with cervical or lumbar facet joint injections (64490 or 64493), cervical or transforaminal epidural steroid injections (64479 or 64483), or cervical or lumbar epidural steroid injections (62310 or 62311).

Step 4: Pay Attention to Editing Bundles

The Correct Coding Initiative (CCI) lists many edits related to ESI procedures.

For example, edits unbundle code 64479 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, single level) from 62310 in the Mutually Exclusive Edits Table. The table also unbundles 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level) from 62311 (Injection[s], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal)). Therefore, for Medicare and other payers who observe the CCI edits, you cannot bill these codes together when the injections are performed to the same spinal area during the same patient encounter.

Scenario: If the physician performs an ESI (billable with 62311) at level L5 and a transforaminal ESI (64483) at area L4-L5, you should only report 62311. However, if the physician administers the ESI (62311) at L5 and the transforaminal ESI (64483) at L3-L4, you can report both injections. Append modifier 59 (Distinct procedural service) to 64483 and list it as the second procedure code on the claim.