Coding Pain Management of the Spine
By David Zielske, MD, CPC-H, CPC-CARDIO, CCS, RCC
Diagnostic spinal procedures include lumbar puncture, myelography, discography, biopsy and aspiration along with plain film radiography, nuclear medicine, CT, and MRI studies. Put these together with the clinical findings of a patient and an action plan for pain management can be formulated. There are many therapeutic options available. This review will focus on image guided percutaneous needle based interventions of the spine for treatment of neck and back pain.
Causes of spine-related pain consist of disease related to the bones of the spine (vertebral body compression fractures, tumor involvement), the joints of the spine (facet arthropathy), the nerves (nerve root compression, irritation and inflammation related to disc compression or neural foraminal stenosis), the intervertebral discs (bulging, herniation, desiccation, infection, the ligaments (ligamentum flavum hypertrophy with associated spinal stenosis) or cerebrospinal fluid (CSF) leaks, or pseudotumor cerebrii.
Vertebral body interventions for pain consist of stabilization of fractures (usually related to osteoporosis or malignancy). Options include vertebroplasty, kyphoplasty, arcuplasty, and radiofrequency ablation. The placement of methylmethacrylate (cement) into the vertebral body (with or without cavity creation) is utilized to treat unrelenting pain related to non-acute vertebral body compression fractures. Most back pain is relieved over time while the fracture heals; however, when the pain persists and is debilitating these interventional procedures resolve pain instantaneously in up to 80 percent of appropriately chosen interventions. The procedure may utilize fluoroscopic CPT® code 72291 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance or CT guidance (CPT® code 72292 under CT guidance) and is usually performed with the patient in a prone position via a unilateral or bilateral transpedicular approach (same codes regardless of approach as long as percutaneous). The guidance codes are used once per vertebral body treated and may be used multiple times if multiple vertebroplasties are performed. If a cavity is created using kyphoplasty (a balloon) and arcuplasty (a bone cutting wire) to perform vertebral augmentation including cavity creation, the CPT® codes used are:
Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical devise, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic
each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)
If the injection of cement occurs without prior cavity creation, it is considered a vertebroplasty and is described by CPT® codes 22520 Pertcutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic, 22521 lumbar and 22522 Pertcutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure). Occasionally, an RF ablation of a bony tumor of the spine is performed for pain control and is described by CPT® code 20982 Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance. This code includes CT guidance. If performed with fluoroscopic guidance, CPT® codes 22899 Unlisted procedure, spine and 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) are used to describe the procedure.
The facet block is perhaps the most common pain management procedure performed. When the facets from adjacent vertebral bodies overlap each other and cause inflammation of posterior bony structures as well as the adjacent nerves, an injection of an anesthetic agent along with a long acting steroid is commonly used. These procedures may be performed at multiple levels and sides. Coding for facet blocks is per joint (there is a right and a left facet joint at each vertebral body level designated by the overlapping facets (e.g. L3-L4 would reference the facet joint involving the L4 superior facet and the L3 inferior facet where they overlap). Modifier 50 is appropriate when bilateral facets are treated. Use the initial facet block CPT® codes 64470 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level and 64475 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level for the first level treated. Use additional level CPT® codes 64472 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) for cervical/thoracic and 64476 lumbar or sacral, each additional level (List separately in addition to code for primary procedure) for lumbar/sacral as often as needed to describe the procedure when performed at multiple additional levels. The facet block is most often performed using fluoroscopic guidance (CPT® code 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), which is billed once per segment of vertebral bodies (e.g., guidance for all lumbar facet blocks is 77003 x 1) regardless of the number of facets treated in the lumbar region.
The same concepts apply to transforaminal epidural injections (sometimes referred to as transforaminal nerve root blocks). The codes follow a similar format as the facet codes. CPT® codes 64479 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level and 64480 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) are used for initial and additional cervical/thoracic transforaminal procedures, and 64483 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level and 64484 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) are used for lumbar treatments. These are coded per side and per level with the guidance used only once per segment of vertebral bodies. In the rare circumstance that a diagnostic epidurogram is performed with this procedure, use CPT® code 72275 Epidurography, radiological supervision and interpretation instead of 77003, and similarly, use it only once for the entire lumbar region regardless of the number of injections performed. The injection of contrast to localize and confirm needle placement and intradural location is not an epidurogram and should be billed as part of fluoroscopic guidance only with 77003.
When pain is related to the disc itself, two percutaneous disc procedures exist to relieve pain and treat the abnormality. These include fluoroscopically guided therapeutic large volume aspiration of disc material (CPT® codes 62287 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any metghod, single or multiple levels, lumbar (eg, manual or automated percutaneous diskectomy, pertcutaneous laser diskectomy and 77002) and for intradiscal annuloplasty, use CPT® codes for initial and additional annuloplasty by electrothermal or by other methods respectively:
Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level
one or more additional levels (List separately in addition to code for primary procedure)
Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; single level
1 or more additional levels (List separately in addition to 0062T for primary procedure)
This procedure bundles the associated fluoroscopic guidance.
For routine caudal (or midline) epidural or subarachnoid injections with anesthetic agent and/or steroids for cervical/thoracic or lumbar/sacral respectively when a single injection is made, use CPT® codes:
Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnosis of therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
62311 lumbar, sacral (caudal)
For continuous infusions at the same locations, use these CPT® codes:
Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
62319 lumbar, sacral (caudal)
(When pain is related to abnormal CSF flow, this will usually present as headaches). CSF leaks from a prior needle puncture may be treated with a blood patch, where some of the patients own blood is injected through a needle into the epidural space to seal the leak (CPT® codes 62273 Injection, epidural, of blood or clot patch and 77003). Another cause of headaches can be increased intracranial pressure related to excess CSF (pseudotumor cerebrii). These patients receive relief by removing a large volume (50 cc – 60 cc) of CSF via a therapeutic lumbar puncture (CPT® codes 62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) and 77003).
Beyond the scope of this article, you should be aware of the many other CPT® codes available for pain management procedures related to nerves, nerve ganglia, joints, ligaments and bones elsewhere in the body. These procedures can be performed by many different physicians (pain specialists, orthopedists, neurologists, neurosurgeons, anesthesiologists, neuroradiologists and interventional radiologists) and in many different locations in your hospital. Happy coding. Dr.z