Part B Insider (Multispecialty) Coding Alert

Payer policies reveal which conditions indicate medical necessity

You need to get up to speed fast if your physician starts offering new services such as epidural steroid injections (ESIs) to help patients with pain, and we've got your CPT, ICD-9 and HCPCS bases covered.

Use this comprehensive look at coding pain management ESI encounters to be sure you're getting every dime you deserve.

Watch the Approach for 62310-62311

The physician likely will choose an interlaminar epidural approach, placing the medicine inside the epidural space.

"As long as the needle is positioned in the epidural or subarachnoid space with the needle [inserted] 'straight' in between the lamina," then the following are the correct codes, says Julee Shiley, CPC, CCS-P, CMC, a coding consultant in Raleigh, N.C.:

• 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).

Pay attention: Be careful not to confuse single injection codes 62310-62311 with the following codes, which you should use for continuous infusion or intermittent bolus:

• 62318 -- Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic subtances, 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).

Look to 64479-64484 for Alternative Approach

If the physician inserts the needle at an angle into the intervertebral foramen to perform an injection at the nerve root area, this is a transforaminal (through the foramen) epidural injection.

With this type of epidural, the physician injects the medication into the lateral epidural space "bathing" a specific spinal nerve as it exits the spinal cord. 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 transforaminal ESIs at the right L4-L5 and L5-S1 intervertebral spaces, two different levels.

You should report 64483 for the first lumbar injection and 64484 for the additional level injection.

Find the Proper Fluoro Code

Increasingly, physicians are using imaging guidance to verify precise needle placement for the ESI. And, in fact, some payers won't cover ESI without this guidance.

Example: Florida Medicare carrier First Coast's policy states, "Epidural injections, regardless of the approach used, should be performed under fluoroscopic or CT-guided imaging. Therefore, injections for chronic pain performed without imaging guidance are considered not medically reasonable or necessary" (go online to http://www.cms.hhs.gov/mcd/search.asp?clickon=search and search for "L6443").

You may report fluoroscopic guidance for an ESI 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). The 2008 Medicare physician fee schedule lists an allowable reimbursement range of approximately $50 to $86 for 77003 (global service), depending on where your office is geographically located.

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

Remember: If another physician performs the injection, the physician can't bill fluoro imaging unless he performed it personally. And you're unlikely to see one physician perform the injection and another bill the fluoro.

Don't get confused: The parenthetical note following 77003 states that codes such as 62310-62319 include "injection of contrast during fluoroscopic guidance and localization." This means that a provider cannot separately bill for the injection of contrast if performed during fluoroscopic guidance, but the note does not restrict you from reporting the guidance (77003) with these epidural injection codes.