Radiology Coding Alert

If you want to keep your pain management program out of the OIG's crosshairs, your transforaminal epidural injection claims need to be squeaky clean.

Here's why: The OIG Work Plan for 2010 includes a closer look at Medicare payments for these injections (http://oig.hhs.gov/publications/docs/workplan/2010/Work_Plan_FY_2010.pdf). The Work Plan specifically states, "We will review Medicare claims to determine the appropriateness of Medicare Part B payments for transforaminal epidural injections."

Follow these steps to be sure you're counting levels and assigning codes correctly.

Physicians often administer transforaminal epidurals laterally through the selected neuroforamen (the natural opening between vertebrae) under fluoroscopy, says Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Mo. Once there, the physician performs an injection at the nerve root area to help relieve the patient's pain. The medication goes into the anterior epidural space, "bathing" a  specific spinal nerve as it exits the spinal cord.

CPT includes four codes to represent transforaminal epidural injections, and you choose from them based on the injection site and number of injections:

• 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).

Procedure note: Although you report the same codes, a transforaminal injection is different from a selective nerve root block (SNRB). With SNRB, your provider injects right beside the nerve root where the nerve exits the foramen. The injection occurs outside the spine, which differs from a transforaminal injection. Coders sometimes interchange the terms, but knowing the difference in technique will help you better understand your physician's documentation.

Although the transforaminal injection descriptors specify spinal levels, your physician actually targets the space between vertebrae -- the interspace. This difference in code terminology and the procedure can confuse coders, so help your chances with the OIG by knowing how to count levels correctly. Remember you're counting interspaces, not vertebral bodies.

Tip: When the provider inserts the needle through the foramen into the interspace between discs (for example, at L4-L5), that is a spinal level you code with 64483. If your provider inserts another needle into the next interspace (for example, at L5-S1), consider that a second spinal level and report +64484 along with 64483.

Important: If your provider injects both sides of the same level, report a bilateral injection, not separate levels. "Payers require various claim formats" for bilateral services, Mehmert says. So get the payer's preference in writing and be sure you don't report treating each side at the same spinal level as treating two different levels.

"Most of the insurance companies I deal with state to use the 50 modifier (Bilateral procedure) and file on one line," says Dawn Shanahan, CPC, supervisor of coding for a Tampa, Fla., group practice. In that case, code a bilateral transforaminal injection at L4-L5 as 64483-50.

Because 64479-64484 have a bilateral surgery indicator of "1" on the Medicare Physician Fee Schedule, payers consider them to be unilateral procedures. Mostinsurers will pay 150 percent for bilateral blocks from this code family.

"Although CPT does not specifically state that fluoroscopy must be used to report these codes, it's almost a universal industry standard to use fluoro," Mehmert says. When your physician uses fluoroscopic guidance report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) in addition to the procedure code.

"There needs to be a mention of the fluoroscopy in the documentation as well as a hard copy of the film in the patient's medical record," Shanahan says. "My physician mentions the use of fluoro, as well as the type and amount of dye used or if the dye was not used and why."

Analyze policies: Know your payers because insurance companies have different guidelines for how many levels the physician may inject during the same encounter, the time between procedures, and other parameters. For example, one of Shanahan's payers "states that a patient can receive diagnostic injections no sooner than every week, whereas the therapeutic injection time is no sooner than eight weeks."

Other payers, however, have policies that deny treatment as not reasonable or medically necessary when your physician administers combinations of epidural, facet, lumbar sympathetic, or bilateral sacroiliac joint blocks on the same day.