Report Transforaminal Epidural Injections With Precision
With OIG keeping a watchful eye on these interventions, be sure your coding is straight and narrow.
By G. John Verhovshek, MA, CPC
A sharp rise in reporting transforaminal epidural injections in recent years has prompted the Office of Inspector General (OIG) to scrutinize these services as part of its 2010 Work Plan. Keep yourself out of the OIG’s crosshairs with these seven coding tips.
1. Choose the Correct Approach
Transforaminal epidural injections (CPT® 64479-64484) are an interventional technique to diagnose or treat pain, such as pain that starts in the back and radiates down the leg. A long-acting steroid is injected laterally through the natural opening between the vertebrae (the neuroforamen) to place medication in the anterior epidural space and target a specific spinal nerve.
The translaminar epidural approach, by contrast, places the medicine inside the epidural space. Report these procedures using 62310-62311, depending on the targeted spine region (cervical/thoracic or lumbar/sacral).
2. Code by Spinal Region
Codes describing transforaminal epidural injections are specific to the targeted spine region (cervical/thoracic or lumbar/sacral):
Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level
Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level
Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
3. Report per Level, Not per Injection
The American Medical Association’s (AMA’s) CPT® Assistant (Feb. 2000) confirms that 64479-+64484 are to be reported once per level targeted, “regardless of the number of [unilateral] injections performed at a particular spinal level.” Report additional code units only when the physician targets different levels.
Terminology alert: Although the code descriptors specify “levels,” these injections target the area between the vertebrae (i.e., the spinal interspace), rather than an individual vertebra. For instance, two left side injections at C3/C4 and two left side injections at C4/C5 represent two levels (although they involve three vertebrae and, in this case, four separate injections), and are reported 64479-LT Left side for the initial level and one unit of 64880-LT for the second level.
4. Apply Modifiers to Specify Location
Codes 64479-+64484 describe unilateral procedures; and because there are separate nerves on each side of the spine, these procedures may be performed bilaterally at the same spinal level(s). “When a transforaminal injection is performed on the opposite side, the work may involve redraping and positioning of the patient,” advises CPT® Assistant (Sept. 2005). “Therefore, when performing bilateral transforaminal epidural injections at a single spinal level, modifier 50 [Bilateral procedure] is appended to the appropriate code(s).” As an example, the physician provides one right side injection and one left side injection at L1/L2. In this case, the appropriate coding is 64483-50.
The Medicare physician fee schedule relative value file assigns 64479-+64484 a bilateral surgery indicator of 1, so most insurers will pay 150 percent of the standard fee for bilateral injections.
As shown by example in our third tip, modifiers LT and RT Right side also may be used to designate location for unilateral injections.
5. Claim Guidance Separately
Epidural injections require imaging guidance to place the needle precisely. CPT® Assistant (Feb. 2000) explains, 64479-64484 “are performed under fluoroscopic guidance for precise anatomic localization to avoid potential injury to the vertebral artery or damage to the spinal cord or surrounding nerve roots.” CPT® further instructs, “For fluoroscopic guidance and localization for needle placement and injection in conjunction with 64479-64484, use 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].”
Report a single level of 77003 per session, regardless of the number of levels/injections involved. Confirm in the documentation that guidance was used, and include a hard copy of the film in the patient record.
For example, documentation might state:
The lumbar spine was prepped and draped in a sterile manner. The C-arm was brought into view and the right side of the L2/L3, L3/L4, and L4/L5 transforaminal areas were visualized. Skin was marked and infiltrated with 1 percent Xylocaine. 22g, 3½ inch Quincke-type spinal needles were inserted into the transforaminal area and were advanced in the lateral view. In the AP view, 2 cc of Isovue were injected revealing adequate neurograms with medial spread. 20 mg of Kenalog with 1 cc of .25 percent bupivacaine at each level.
In this case, report:
• 64483-RT for the initial injection
• 64484-RT for the subsequent injection at L3/L4
• 64484-RT for the subsequent injection at L4/L5
• 77003 for fluoroscopic guidance (C-arm)
Beware of inappropriate bundling: Although some payers may attempt to bundle guidance into the injection procedure, the American Society of Anesthesiologists (ASA) stresses, “Fluoroscopic guidance is reported and valued separately from spinal injection procedures. CPT® instructions are clear and unequivocal. Medicare and other payers who use the CCI edits allow the reporting of 77003 along with codes.” For more information, view the ASA’s memorandum.
6. Establish Medical Necessity
To establish medical necessity for spinal injections, the claim form must cite, and documentation must support, an appropriate diagnosis. Allowable diagnoses may vary by payer (Check with your particular payers for specifics.); however, commonly-allowable ICD-9-CM codes to establish medical necessity for 64479-64484 include intervertebral disc disorders (722.x), spinal stenosis (723.0 Spinal stenosis in cervical region, 724.0x), post-laminectomy syndrome (722.8x), and radiculitis (723.4 Brachial neuritis or radiculitis NOS, 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified), among others.
7. Observe Frequency Guidelines
Many payers will place limits on the number of levels a physician may inject during a single encounter, as well as the time between procedures and the maximum number of injections allowable over time.
As an example, the payer may state that if there is no documented pain relief after two injections, no further injection will be considered medically necessary at the same level. Or, the payer may limit reimbursement to no more than three injection series in a calendar year. Again, check with your individual payer for these guidelines.