Neurology & Pain Management Coding Alert

Plus: Contractors are also auditing place of service, bilateral services, and consolidated billing.

Your practice may have grown accustomed to the presence of recovery audit contractors (RACs) in the Medicare world, but it can still be hard to follow the issues that the RACs investigate. Two RAC regions recently posted focus areas every pain management practice needs to know. Check out what they're seeking and how you can avoid the auditors' crosshairs.

Watch Diagnosis With Transforaminal Epidural

Region C RAC Connolly will be reviewing claims for "transformational epidural injections." This appears to be a spelling error, with the RAC referencing articles about transforaminal epidural injections (rather than "transformational").

The RAC notes that "claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies."

What it means: The Medicare contractor has an LCD (local coverage determination) with specific ICD-9 codes that support medical necessity for the injections. The RAC audit is data mining to determine whether any claims were paid for diagnoses (ICD-9 codes) that were not included in the LCD list.

Keep in mind: When the physician administers a transforaminal epidural injection (such as 64479-64484), the documentation must include the patient's pain history, descriptions of failed conservative measures, and details of the patient's spinal pathology. For more on how to correctly report these services, read MLN Matters article SE1102 at www.cms.gov/MLNMattersArticles/Downloads/SE1102.pdf.

Don't Double Dip With Bilateral Billing

DCS Healthcare, the region A RAC, has spent the last year reviewing "overpayments associated with providers incorrectly billing services with bilateral indicator 3 (100 percent payable for each side) on multiple lines; once with modifier 50 (resulting in 200 percent payment) and once without modifier 50 (resulting in 100 percent payment), resulting in a 300 percent total payment."

"Your provider's contracts with different insurance companies might have a section on bilateral procedures and how they're to be billed," notes Dawn Shanahan, CPC, supervisor of coding for Florida Gulf to Bay Anesthesiology Associates in Tampa. "If so, you need to follow these guidelines or you might not get paid."

Remember: Medicare requires bilateral (mirror-image) services to be reported with modifier 50 (Bilateral procedure). You'll report the bilateral service on one line item, with the CPT® code appended with modifier 50 and one unit of service. Other payers may prefer that you report the codes on separate line items using the RT (Right) and LT (Left) modifiers, you'll report two listings of the same CPT® code, but you won't append modifier 50.