Radiology Coding Alert

Facet joint injection coding foul-ups -- resulting in $96 million in improper payments -- prompted a recent CMS clarification on proper modifier 50 use. Here's what you need to know to keep your claims in the clear.

The gist: A recent OIG report on 2006 services found that doctors incorrectly assigned facet joint add-on codes to report bilateral injections. CMS released MLN Matters article MM6518 (effective date August 31) to explain how to code these procedures properly.

Both the OIG and CMS focus on these codes:

• 64470 -- Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level

• +64472 -- ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

• 64475 -- ... lumbar or sacral, single level

• +64476 -- ... lumbar or sacral, each additional level (List separately in addition to code for primary procedure).

Bilateral: If you perform injections at the "right and left at the same interspace, you have done two procedures," says Scott Groudine, MD, professor at Albany Medical Center in New York.

Instead of using an add-on code (+64472, +64476), you should append modifier 50 (Bilateral procedure) to your facet joint injection code (64470, 64475) for bilateral services performed on the same level, explains MLN Matters article MM6518.

For example, for injections at the right C5-C6 and left C5-C6, you should report 64470-50.

Multiple levels: You should use the add-on codes (+64472, +64476), which specify "additional level" in their descriptors, only if the doctor performs facet joint injections on more than one level. For example, for unilateral injections of C3-C4 and C4-C5, you would report 64470 and +64472.

Bilateral lumbar facet procedures reimburse at 150 percent of the base fee, according to Linda Van Horn, MBA, CEO of 21st Century Edge, at a conference of the Society for Pain Practice Management in Phoenix. The good news is that 150 percent of Medicare's national nonfacility rate for 64470 (roughly $358) is slightly more than 64470 plus +64472 (roughly $343). And you'll find a similar benefit from reporting 64475-50 properly.

In a facility setting, properly reporting modifier 50 may bring you slightly less than using the add-on codes, but you'll avoid paybacks, payer scrutiny, and possible fraud allegations if you stick to proper coding.

Bonus tip: Don't forget to report guidance for a facet injection with the appropriate code, such as 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).

Resources: You can access the MLN Matters article online at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6518.pdf and read the related one-time notification at www.cms.hhs.gov/transmittals/downloads/R526OTN.pdf. If you'd like to read the OIG's report on facet joint injections, visit www.oig.hhs.gov/oei/reports/oei-05-07-00200.pdf.