Pain Management Coding Alert

Question: The RVUs for 62310 and 62311 were raised in 2015 to include payment for 77003, which we know NCCI edits now include as part of 62310 and 62311. We have issues with three major insurance companies that are processing 62310 and 62311 with the 2014 RVUs and not paying for the 77003. That means our payments are short by $100+ and the three insurers are paying way below the Medicare allowed amount. What should we do?

New Jersey Subscriber

Answer: CPT^® code 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]) should not be paid separately when performed with epidural injections 62310 and 62311. NCCI edits list codes 62310-62319 as Column 1 procedures with 77003 as the Column 2 code.

The descriptors for the epidural procedures in your situation are as follows:

• 62310 – 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; cervical or thoracic

• 62311 – … lumbar or sacral (caudal).

Take note: The edit is retroactive back to Jan. 1, 2015. It supports the 2015 Medicare Physician Fee Schedule that stated Medicare was going to revert back to the 2013 RVUs for these codes but that image guidance would be prohibited from being separately paid with these epidural codes.

The Medicare stance is contradictory to CPT^® directives. Because the first quarter CCI edits for 2015 did not include a bundling edit, some practices mistakenly billed 77003 with these epidural codes and were paid.

Caution: Some practices thought that because they were paid by Medicare, it was appropriate to continue to bill the services separately – but that is fraudulent coding. Practices that have been paid by Medicare in 2015 for 77003 with any of the epidural codes 62310-62319 should consult their healthcare attorney about refunding the inappropriate payments for 2015 dates of service that were previously processed. Medicare contractors will likely go back through their payment files and be reviewing any payment for 77003 with these codes for the same session and request a refund.

Exception: You can potentially bypass the bundling edit between 77003 and codes 62310-62319 with a modifier, but your provider would need to use the fluoroscopic guidance with a different procedure from the epidural.