Anesthesia Coding Alert

Question: The physician was going to do lumbar epidural steroid injections (LESI) under fluoroscopy, but when dye showed poor spread in the epidural space due to scar tissue, he withdrew and then directed the needle into a different position at the pedicle. Good spread was obtained in the transforaminal epidural, so Xylocaine was injected there. At the top of the operative report, the physician reported 62311 and 64483. (The actual documentation was much more detailed.) Can both 64483 and 62311 be charged? Or should modifier -22 be appended to one of the codes to indicate the injection was more difficult than usual? If so, which code would it be appended to?
  
Arizona Subscriber
 
Answer: Codes 62311 (injection, single [not via indwelling catheter], 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; lumbar, sacral [caudal]) and 64483 (injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level) should not be billed separately, says Patricia Bukauskas, CPC, a pain management coding and reimbursement specialist and CEO of TB Consulting, a coding and reimbursement company in Aliquippa, Pa. Because a more extensive procedure, the transforminal epidural, was completed, 64483 is the only code that should be billed.  
 
But if the procedure took extra time and effort, modifier -22 (unusual procedural services) may be appended to 64483. Claims with modifier -22 attached should include complete documentation that explains why the procedure took longer and why the original scheduled LESI was not completed, and should also indicate the additional number of minutes and the added risks and/or complications that prompted the additional work and, hence, the -22 modifier, Bukauskas says. She adds that if the procedure was performed on an HMO or PPO patient and the authorization was for the LESI, the carrier should be contacted to obtain additional authorization for the transforaminal epidural.