Neurosurgery Coding Alert

Physicians billing facet joint injections (64470-64476) must observe strict utilization and medical-necessity guidelines. Careful documentation and complete ICD-9 coding will ensure that claims receive the reimbursement they deserve. In addition, properly reporting fluoroscopic guidance will increase both coding accuracy and your bottom line. Observe Utilization Guidelines for Multiple Injections Most payers will reimburse a maximum of three facet joint injections per session, each at a different spinal level. In addition, payers typically limit the total number of injections the physician may bill for the same patient within a given time frame. For example, Aetna U.S. Healthcare (a large private payer) instructs physicians, "Facet joint injections should be limited to a maximum of three sets of injections over a 12-month period." Aetna defines one "set of injections" as treatment of up to three anatomic sites during a single session. Either individual spinal levels or the left and right sides of a single level count as a separate anatomic site (that is, a bilateral injection counts as two anatomic sites). Medicare carriers observe similar restrictions. Empire Medicare, the Part B provider for New Jersey, instructs in its local medical review policies (LMRP) for facet joint injections, "Claims for an unusually large number of facet nerve blocks will be denied as not ... necessary in the absence of supportive documentation," and, more explicitly, "Provision of more than three levels of facet joint blocks on the same day is not considered medically necessary."

Note, however, that the first statement does leave open the possibility of payment for more than three injections per session under the appropriate circumstances. Specifically, the LMRP seems to indicate that if the physician targets the facet nerve (that is, the median branch nerve), rather than the facet joint and he or she provides appropriate documentation the payer may allow the claim. But not all payers make the distinction between facet nerve and facet joint injections. Check with your payer for its guidelines prior to billing Note: For information on injection of facet nerve versus facet joint, see Neurosurgery Coding Alert, December 2002. Documenting Medical Necessity Generally, payers will reimburse for facet joint injections when the patient has "chronic pain." Be aware, however, that the definition of chronic (as opposed to "acute") pain differs from payer to payer, says Patricia Bukauskas, CPC, a pain management coding and reimbursement specialist and CEO of TB Consulting, a coding and reimbursement company in Aliquippa, Pa. For instance, Empire says, "Chronic pain is defined as pain which has been present for six months or more," while Aetna requires only three months to pass. Regardless of payer, the physician must document a history of pain for the minimum specified time. Empire's LMRP makes this point very [...]