Neurology & Pain Management Coding Alert

Good news: Providers can report fluoro guidance with tendon injections.

Hundreds of new coding edits – including all nerve injection and destruction procedures – went into effect on July 1 for neurology and pain management specialists, thanks to the CCI (Correct Coding Initiative) 19.2. The biggest news for neurology and pain management is that you’ll need to pay close attention to changes in modifier indicators.

Don’t Miss Modifier Indicator Changes

Many modifier indicators for epidural (62310-62319) and nerve injection (64400-64530) procedures bundled into nerve destruction and chemodenervation procedures (64610-64681) have changed. 

“Prior to 19.2, these bundling edits did not allow a modifier to bypass the edits,” explains Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. “Effective July 1, 2013, the modifier indicator for many of these pairs changed to ‘1,’ meaning that if the documentation supports use of a modifier to bypass the bundling edits, then the Column 2 code could be separately reported with the corresponding modifier.”

EMG change: CCI 19.2 also changed modifier indicators in the reverse (from “1” to “0”) for the add-on EMG codes (+95885--+95887) when reported as Column 2 codes bundled into the Column 1 codes for needle EMG services 95860-95864, 95869, and 95870. The change means that effective July 1, 2013, a provider cannot separately bill for EMG testing performed with NCS when the codes for performing EMG testing without NCS are billed.

Also of note: CCI 19.2 brings good news for practitioners who administer ligament and tendon injections. Previous bundling edits with injections 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar “fascia”]) and 20551 (…single tendon origin/insertion) as the Column 1 codes paired with Column 2 code 77002 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]) were deleted, effective June 30, 2013. That means the fluoroscopic guidance is no longer bundled into the ligament and tendon injection codes.

Don’t Jump to Report E/M With Injections

The other hundreds of edits applicable to most providers aren’t so intimidating  once you take a closer look.

Here’s why: Virtually every edit associated with pain management services includes the same set of approximately 50 E/M codes. As long as you remember that the injection procedure probably overrides the E/M service, your coding will be simple.

According to CCI 19.2, report these injections alone instead of in conjunction with E/M codes:

• 20550-20551  for tendon and ligament injections
• 20552-20553 for trigger point injections
• 20600 – 20610 for aspiration or injection of small, intermediate and major joints or bursa
• 27096 for sacroiliac joint injections
• 62310-62318 for continuous or single-shot epidural placement
• 64400-64681 for nerve injection and destruction procedures.

Several spine procedures are also part of the same edit structure, with these procedures listed as the ones you should report instead of E/M services on the same day:

• 22520-22521 for vertebroplasty
• 22523-22524 for kyphoplasty
• 22526 for IDET.

“These ‘new’ edits aren’t really new, as several chapters in the CCI Manual address the requirement for separately reporting E/M services on the same day as a procedure,” says Hammer.

Learn the List of Affected E/M Codes

The edits all involve E/M services, so once you get familiar with the applicable E/M codes, most of your work is done. The following E/M services are bundled into the procedures listed above and should not be separately reported under normal circumstances: 

• Patient office visits (99202-99205 for new patients or 99212-99215 for established patients)
• Initial hospital observation care (99218-99220)
• All hospital inpatient E/M services (99221-99239)
• All inpatient and outpatient consultation services (99241-99255)
• Critical care services (99291 and +99292)
• Nursing facility services (99304-99316)
• Most domiciliary and home services (99324-99350)
• Four codes for care plan oversight services (99374, 99375, 99377, and 99378).

Background: E/M services have always been considered part of a procedure by virtue of the rules defining global periods. Minor procedures (those with 0- and 10-day global periods) have included a minor E/M procedure that was not “significant and separately identifiable.” Major procedures (with a 90-day global period) have always included any E/M services provided the day of and the day before the procedure.

Double Check for Modifier Possibilities

The vast majority of pain management edits are due to “CPT^® manual or CMS manual coding instructions.” Nearly all edit pairs carry a modifier indicator of “1,” however, meaning that you might sometimes be able to report both services in an edit pair when they’re completed during the same encounter. If you have clear documentation that justifies reporting both services, include that information with your claim and append a modifier (such as 25, Significant, separately identifiable E/M service or 57, Decision for surgery) to the E/M code. 

“So, just like we have always used the 25 and 57 modifiers because of the global rules with minor and major procedures with E/M services, we will continue to use these modifiers when they have been appropriately documented and the circumstances support their use,” Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “This bundle really has not changed how minor and major procedures with E/M services are coded and handled. It just adds another level to the regulations via the CCI.”