Anesthesia Coding Alert

Imaging guidance update may bring lower pay for 64415-64417 and 64445-64448.

If you report somatic nerve injections for postoperative pain management, you won’t want to miss important CPT® updates for 2023. The changes to these codes will affect how you report these injections when the provider uses imaging guidance.

Here’s what you need to know about these changes from CPT^®, effective Jan. 1, 2023, along with news of some potential payment changes for these codes announced in the 2023 Medicare Physician Fee Schedule (MPFS) proposed rule.

Understand How ‘Imaging Guidance’ Addition Affects Coding

The codes that will change in 2023 are 64415-64417 and 64445-64448, which all share this common start to their descriptors: Injection(s), anesthetic agent(s) and/or steroid ….

“Anesthesia practices have used these codes for many years to report postoperative pain management. They bill ultrasound separately for imaging guidance, and this will be a major change,” says Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. “Ultrasound is popular to use as it reduces the chance of patients having adverse effects,” she adds.

In fact, “the specialty societies stated that CPT^® codes 64415, 64416, 64417, 64446, 66447, and 64448 were reported with the imaging code CPT^® code 76942 [(Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation)] more than 50 percent of the time,” the 2023 MPFS proposed rule states (www.federalregister.gov/d/2022-14562/p-506).

What’s changing: CPT^® 2023 will add “including imaging guidance, when performed” to the descriptors for these codes. That means you will no longer report ultrasound (such as 76942) or other types of imaging guidance separately when the provider uses that guidance to perform services you report using 64415-64417 and 64445-64448. The examples below help demonstrate how these descriptor revisions will affect your coding.

Old way: For a 2022 date of service (DOS), suppose an anesthesiologist at a facility uses ultrasound guidance to perform a brachial plexus anesthetic injection for post-op pain management on the same date as performing anesthesia for the operation. You report the injection and guidance using these codes:

• Injection: Report 64415 (Injection(s), anesthetic agent(s) and/or steroid; brachial plexus) and append modifier 59 (Distinct procedural service) or XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).
• Guidance: Report 76942 with modifier 26 (Professional component).

New way: Consider the same example as above, but for a 2023 DOS. You will report only one procedure code:

• Injection and guidance: Report 64415 (… brachial plexus, including imaging guidance, when performed) with modifier 59 or XU attached.

You should append modifier 59 or XU based on Medicare’s National Correct Coding Initiative Policy Manual, Chapter II.B.4. It states that if you report a peripheral nerve block injection (64400-64530) for post-op pain management on the same DOS as an anesthesia 0XXXX code, you may append modifier 59 or XU to the peripheral nerve block code to show it was for post-op pain management.

Bonus tip: The 2023 descriptors state the codes include “imaging guidance, when performed,” so you will report the code regardless of whether the provider uses imaging guidance. You should not append a modifier such as 52 (Reduced services) to indicate the provider did not use imaging guidance.

Look Ahead to Payment Changes

Because the injection codes will include imaging guidance time and services, the 2023 proposed MPFS includes potential updates to the work relative value units (RVUs) for these codes. “This is a huge change that will affect payments,” says Dennis.

You can expect all the injection services with imaging guidance to have a reduction in work RVUs in 2023. The table compares the proposed 2023 injection code work RVUs to the 2022 work RVUs for the injection code plus ultrasound guidance (76942). Remember that work RVUs are part of the basic formula to determine the MPFS payment amount:

(Work RVUs + practice expense RVUs + malpractice RVUs) x MPFS conversion factor.

Geographic location also will affect final payment. The final work RVUs for these codes may differ, so be sure to check the final MPFS rule when it is available.