Eli's Rehab Report

The U. S. Food and Drug Administration approved intradiscal electrothermal (IDET) therapy in 1998 to treat patients with chronic discogenic pain. Because IDET doesnt have an established CPT code, many insurance carriers are still unfamiliar with it, and may deny reimbursement for the procedure. Practices that consistently obtain insurance pre-approval and are aware of the correct unlisted code (64999, unlisted procedure, nervous system), including the correct codes for related procedures, will have IDET well-documented if audited.

When Is IDET an Option?

With age or injury, cracks or fissures may develop in the wall of the intervertebral disc, says Stephen Endres, MD, staff pain specialist with the Miller-Dwan Pain Center in Duluth, Minn., and the Pain Clinic of Northwestern Wisconsin in Eau Claire. These fissures can be a chronic source of pain in many patients, and sometimes the inner disc tissue can herniate into the fissures, stimulating pain sensors within the disc.

Before doing an IDET procedure, we have to ensure that the patient has whats called discogenic pain, (ICD-9 722.0 -ICD-9 722.9 , intervertebral disc disorders) and not pain from herniated discs or a pinched nerve, says Endres. When we see a patient who presents with months or years of low back pain worse when they sit and stand, that radiates into, for example, their buttocks or tailbone, with very little radiation down the leg or numbness or tingling in the leg we usually take the next step to determine whether they have discogenic pain.

The next step, says Endres, is magnetic resonance imaging (MRI) (72148-72149 and 72156-72158). The MRI reveals a disc or discs that show signs of wear and tear or degenerative changes, and usually a disc that is producing pain will show desiccation, or loss of water content. Sometimes the radiologists can find a tear in the disc during the MRI.

If the MRI shows changes in the disc, says Endres, depending on what stage the pain is, and if the patient hasnt had therapy, then our pain clinic probably performs physical therapy (normally 97110-97150) and pain management injections (20550, 62280, 62282, 62311, 64475-64476, 64483-64484). If these conservative therapies still dont help the patients pain, we perform diskography, which is the gold standard for making the diagnosis.

During diskography, says Endres, a needle is placed in the patients disc. We use pressure monometry to create physiological pressure representing the actual tension the disc is under when the patient is sitting and standing. A lot of times, the dye fills the cracks and we can actually see the tears in the disc. If were lucky, as we see the tear open, the patient says, Thats where the pain is at the same time.

Code the radiological supervision and interpretation of diskography with 72295 (diskography, lumbar, radiological supervision and interpretation), says Marlene Luginbill, biller at the Pain Clinic of Northwestern Wisconsin in Eau Claire. Bill the injection procedure for diskography 62290 (injection procedure for diskography, each level; lumbar).

Performing IDET

After we diagnose that one or two discs are causing the pain, then the patient is a candidate for IDET, says Endres. He describes the procedure as minimally invasive, performed on an outpatient basis. The physician applies thermal energy, or heat, to a section of the affected disc wall, and then inserts a flexible catheter into the center of the disc. The catheter rests along the injured area of the disc wall, while the generated heat contracts and thickens the discs collagen.

Even though some practices may be coding IDET with 62287 (aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar), Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., says the American Medical Association (AMA) (January 2000 CPT Assistant) and Medicare require 64999 (unlisted procedure, nervous system) for IDET coding. Callaway-Stradley cautions, Be sure to document the IDET procedure in a form letter describing the work you did in detail and send the letter with the claim. If you asked an insurance company for preauthorization, send this detailed documentation letter to the insurance company at the time of the pre-authorization request.

Following the IDET procedure, Endres braces his patients with a cloth corset and cautions them to refrain from physical activities during the first month. Two weeks after the IDET, Endres physical therapist sees the patient and assesses the recovery progress (97001, physical therapy evaluation; 97002, physical therapy reevaluation). One month after IDET, Endres and the therapist both see the patient.

Preauthorization Is Key

Were getting all of the IDET procedures pre-approved before performing them, says Luginbill, because there are so many insurers who still believe its investigational or experimental and wont pay. But those who do pay are paying quite well. Weve had a lot of success with those insurers.''