Neurology & Pain Management Coding Alert

Remember one important modifier for claims success.

Information on new and revised procedure or diagnosis codes is easy to find each year, but don't forget the coding guidelines from CPT®, ICD-9, HCPCS, and other sources.

For example, the 2012 Correct Coding Initiative (CCI) coding guidelines include information about reporting post-operative pain management and spinal injections that your pain management specialists will need to know. Read on for details, thanks to a guideline analysis from Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner of Precision Auditing and Coding.

Check and Clarify Post-op Time and Purpose

Medicare global surgery rules specify that the surgeon performing the procedure is responsible for post-op pain management and should not report the care separate from the surgery. The rules change, however, when the surgeon asks a pain management specialist to handle the patient's post-op treatment.

Before requesting the specialist's help, the "actual or postoperative pain must be severe enough to require treatments beyond the experience of the operating physician," CCI guidelines state. For example, the surgeon might request that the pain management physician to place a catheter for a continuous epidural infusion or nerve block to treat the patient's post-op pain.

Remember: The specialist might choose to place the epidural before, during, or after the surgery. You can only code the service, however, if the epidural catheter or nerve block is not also used as part of the anesthesia administration during surgery. If it is, you should only report the appropriate anesthesia code for the surgery and not separately code for post-op management.

When you can legitimately report the post-op management, look at coding options such as:

• 62310 or 62311 -- Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid ...
• 62318 or 62319 -- Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid ...
• 64400-64530 -- Codes for introduction/injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures on the extracranial nerves, peripheral nerves, and autonomic nervous system.

Append modifier 59 (Distinct procedural service) to indicate that the specialist placed the nerve block or catheter for post-op management instead of intraoperative anesthesia. Remind the provider to include a procedure note in the patient's record documenting the block's purpose.

Post-global details: The surgeon might sometimes request pain management services after the postoperative anesthesia care period ends. You can code for this situation without worrying that the care might be misinterpreted as part of the surgical anesthesia. However, CCI guidelines clarify that you still should append modifier 59 to the appropriate code for pain management services.

Stick With Single Primary Code, Even With Different Spinal Areas

Chapter 8 of the CCI Guidelines (Surgery, Endocrine, Nervous, Eye and ocular Adnexa, and Auditory Systems) includes new clarifications about spinal coding.

CPT® groups the codes for many spinal procedures into "families" that include a primary procedure code for a single level of the spine (cervical/thoracic or lumbar/sacral). The code family often includes add-on options for reporting the same procedure at additional levels of any spinal region.

CCI guidelines state, "For these types of spinal procedures, a provider should report only one primary code within the family of codes for one level and should report additional contiguous levels utilizing the add-on code(s) in the family of codes."

Example: CPT® codes 22520-22522 describe percutaneous vertebroplasty. Code 22520 describes percutaneous vertebroplasty of a single thoracic vertebral body; 22521 describes percutaneous vertebroplasty of a single lumbar vertebral body; and 22522 is an add-on code describing percutaneous vertebroplasty of each additional thoracic or lumbar vertebral body. If a physician performs percutaneous vertebroplasty on contiguous vertebral bodies such as T12 and L1, you should report only one primary procedure code. Report the procedure on the second vertebral body with 22522 (Percutaneous vertebroplasty [bone biopsy included when performed], 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body [List separately in addition to code for primary procedure]).

Resource: CCI coding guidelines are specific to Medicare. CPT® or other payers might have different directives or rules for you to follow, so always verify guidelines before submitting your claim. Find the complete CCI Manual online at http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp.