Move Over Obsolete Pain Management Coding

Part 1: Make room for the latest in CPT® coding.

By Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, and G.J. Verhovshek, MA, CPC

CPT® 2012 brings important changes to pain management coding. In the first of this two-part series, we’ll:

Ambulatory Surgical Center CASCC

  • Review the revised coding guidelines for sacroiliac (SI) joint injection.
  • Clarify the methodology for determining when to use the “open” versus “percutaneous” codes for disc procedures, and corresponding changes to code 62287.
  • Explain how to code the use of a catheter for a single epidural injection.
  • Go over the new codes for facet joint nerve destruction.

SI Joint Injections Include Imaging Guidance

Code 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed has been revised for 2012 to include image guidance by fluoroscopy or computed tomography (CT) to confirm intra-articular needle positioning. Arthrography is also included, when performed. The corresponding radiology code (73542) has been deleted, and a new parenthetical note directs providers to use 27096 for arthrography. CPT® continues to direct providers to append modifier 50 Bilateral procedure for bilateral injections.

For example: The physician performs a right SI joint injection for sacroiliitis with 6 mg of steroid and 1 mL of 0.5 percent local anesthetic. Intra-articular needle placement was verified fluoroscopically with an injection of 0.5 mL low osmolar contrast. In this case, physician coding would be 27096-RT x 1 with a diagnosis of 720.2 Sacroiliitis, not elsewhere classified. Modifier RT indicates that the injection occurred on the right side.

Per CPT® Assistant (April 2004), CPT® 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) historically has been reported for an SI joint injection without image guidance; however, a parenthetical note in CPT® 2012 now instructs, “If CT or fluoroscopic imaging is not performed, use 20552 [Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)].”

Note: Medicare HCPCS Level II codes G0259 Injection procedure for sacroiliac joint; arthrography and G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography, used for ambulatory surgical centers and hospital outpatient place of service (POS), are unchanged for 2012.

Code 62287 Now Specifies Needle-based Procedures

CPT® code 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar has been revised to specify a needle-based procedure that may include an endoscopic approach. The procedure removes part of the nucleus pulposus, the gel center, from a herniated disk, to decrease pressure on a spinal nerve root and relieve pain.

Code 62287 now includes fluoroscopic guidance, as indicated by the revised code descriptor. Also included and not separately reportable are percutaneous aspiration with the nucleus pulposus (62267), discography injection (62290), and diagnostic/therapeutic lumbar injection (62311). You should continue to report 62287 as a single unit of service for “single or multiple levels,” and only for the lumbar spine.

The “Spine and Spinal Cord: Injection, Drainage or Aspiration” section guidelines now clarify the difference between indirect versus direct visualization. The use of an endoscope to perform a procedure does not determine the procedure coding; rather, the physician’s visualization of the disc, spinal cord, and neural space does.

The new guidelines indicate, “Percutaneous spinal procedures are done with indirect visualization (e.g., image guidance or endoscopic approaches) and without direct visualization (including through a microscope)” and “Endoscopic assistance during an open procedure with direct visualization is reported using excision codes (e.g., 63020-63035).” For a non-needle-based technique for percutaneous decompression of nucleus pulposus of intervertebral disc, CPT® directs you to 0274T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic and 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar.

For example, for percutaneous L4-L5 discectomy (PLD) with aspiration under fluoroscopic guidance for L4-L5 bulging disc, physician coding is 62287 (one unit of service) with a diagnosis of 722.10 Lumbar intervertebral disc without myelopathy.

For bilateral L4-L5 percutaneous decompressive laminectomy under fluoroscopic guidance, and epidurogram confirmation for central lumbar stenosis with neurogenic claudication, the proper coding is 0275T (single unit of service) with 724.03 Spinal stenosis; lumbar region, with neurogenic claudication.

In a final example, endoscopically assisted open hemilaminectomy with right L4 nerve root decompression for L4-L5 disc herniation would be reported 63030-RT and 722.10.

Code Diagnostic/Therapeutic Injections by Location, Duration

CPT® section guidelines and code descriptors for 62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic and 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) have been revised, to include injection(s) that may involve threading a catheter into the epidural space, injecting substances at one or more levels, and removing the catheter on the same calendar day.

If the catheter is left in place to deliver substance(s) over a prolonged period (i.e., more than a single calendar day), either continuously or via intermittent bolus, report instead 62318 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic or 62319 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal), as appropriate.

Some physicians use a catheter for cervical epidural injection(s) via the intralaminar approach at C7-T1 due to increased risk of intravascular injection with transforaminal epidural injections in the upper cervical levels. Alternately, physicians may need to use a catheter via a caudal approach to access the lower lumbar spinal levels if the patient has spinal hardware or previous laminectomy surgery. In either of these scenarios, regardless of the number and/or levels of injections, if the catheter is removed following the epidural injections (on the same calendar day), the compliant coding would be 62310 or 62311, not 62318 or 62319.

Final code choice is based on the region at which the needle or catheter entered the body (e.g., lumbar). The procedures should be reported only once when the substance injected spreads or the catheter tip insertion moves into another spinal region. For example, report 62311 one time for injection or catheter insertion at L3-L4 with substance spread or catheter tip placement into the thoracic region.

Report Facet Joint Destruction per Joint, Not per Injection

With the deletion of 64623-64627, coding for paravertebral facet join destruction is now based on destruction of the sensory innervation to each facet joint, not per facet joint nerve, as in the past:

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

+64634 each additional facet joint (List separately in addition to code for primary procedure)

64635 lumbar or sacral, single facet joint

+64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Image guidance (fluoroscopy or CT) is now required, and is no longer separately billable with either 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) or 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation. Facet joint nerve destruction continues to be considered a unilateral procedure; you may append modifier 50 for bilateral facet joint nerve destruction.

For example, to describe radiofrequency ablation of the C3, C4, and C5 medial branches, you would report 64633, 64634 because the sensory innervation to two facet joint levels, C3-C4 and C4-C5, was neurolysed. For bilateral L3-L4, L4-L5, and L5-S1 facet joint neurolysis (i.e., L2, L3, and L4 medial branches and L5 dorsal ramus), correct coding would be 64635-50, 64636-50 x 2 units of service (or, depending on your payer, 64635-LT Left side, 64635-RT and 64636-LT x 2, 64636-RT x 2).

Note: Continue to report pulsed radiofrequency ablation (which is not considered a method of destruction) using an unlisted procedure code (64999 Unlisted procedure, nervous system).

Next month, we’ll discuss revised combination codes for pump refill and programming, coding methodology changes for “simple” versus “complex” neurostimulator programming, and related concerns.

 

Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, is owner of MJH Consulting in Denver, Colo.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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