Eli's Rehab Report

Nugget: The new fluoroscopy code is useful, but dont unbundle if you are using an injection code that already includes fluoroscopy.

Fluoroscopic guidance often is used to increase the accuracy of therapeutic and diagnostic injection sites, but coding for it can be confusing. Knowing when to bill with a modifier can help billers avoid delays in receiving reimbursement for this technical procedure.

Practices using fluoroscopy for needle placement during pain management injections can benefit from using the new fluoroscopy code, 76005 (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), but must be careful to note that the fluoroscopic guidance already is bundled into certain injection procedures, says Nancy Burton, CCS, a biller at Physicians Administrative Services, a healthcare reimbursement consulting firm in Torrance, Calif., that handles the billing for more than 100 physicians.

From a pain management standpoint, fluoroscopy is used most often for spinal injections, and many of those spinal injection codes already bundle the fluoroscopy code into them, says Burton. CPT Codes 2000 states, Injection of contrast during fluoroscopic guidance and localization is an inclusive component of codes 62270-62273, 62280-62282, 62310-62319 [spine and spinal cord injection codes]. For example, if the physician is placing an epidural (62270) in a patient with a herniated lumbar disc (722.10 ), the doctor could not bill separately for the fluoroscopy.

The only way to retrieve any money for fluoroscopy with those codes, says Burton, is if the doctor performing the fluoroscopy does not own the C-Arm machine, which is necessary in these procedures. In those cases, you could bill using the modifier -26 (professional component) and the 76005.

Why Physiatrists Bill for Fluoroscopy

Fluoroscopy is used to visualize the exact location of needle placement or using contrast mixed in with the injection solution, says Gregory Mulford, MD, advisor to the American Medical Association (AMA) CPT advisory committee for the American Academy of Physical Medicine and Rehabilitation, and chairman of the department of rehabilitation medicine at Morristown Memorial Hospital in New Jersey. Typically, its used for selective nerve root blocks to identify a specific nerve root, but it is sometimes used for epidurals and facet branch blocks.

Coders should note that 76005 can be billed with paravertebral facet joint injection codes (64470-64476) and transforaminal epidural needle placement and injection (64479-64484). Billers should be aware that many commercial insurance carriers are still not recognizing fluoroscopy codes, says Burton. In 2000, Medicare will pay a facility charge of $77.25 for the 76005, and with the modifier -26, it pays $31.57. You should always use the right codes, but if you are having problems receiving reimbursement for the 76005, your practice has to weigh the amount it costs you to retrieve that $77.25 against the actual benefits. It is important, however, to always bill for everything your office does so your records match your bills.

Modifiers -51 and -50

Some coders may use modifier -51 (multiple procedures) when billing for multiple spinal injections with fluoroscopy, says Burton, But the -51 modifier is valid only if youre doing the fluoroscopy on different body parts, if youre working on the spine, then you did fluoroscopy to check out something peripheral like the leg, for example. Fluoroscopy used on both sides of the spine would be indicated by using the modifier -50 (bilateral procedure).

Coders should note that the new facet joint and epidural injection codes (64470-64484) pay by the level of service, and that doctors notes indicating spinal positions such as L4-L5 refer to the single joint between the two vertebrae and would thus represent a single level.