Neurosurgery Coding Alert

Question: Our surgeon does a right C2 parafacet and epidural steroid injections as well as right trigger point injections in the front parietal region. How do we report this?

North Carolina Subscriber

Answer: You report 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single level) for the parvertebral injection. Note that your surgeon must have used imaging guidance and localization for the performance of paravertebral face joint injections. Procedures described by 64490-64495 require fluoroscopic or CT guidance in order to use these codes. Otherwise, if imaging is not used, you should report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s])-20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]). If ultrasound guidance is used, report 0213T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance, cervical or thoracic; single level)-0218T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance, lumbar or sacral; third and any additional level[s] [List separately in addition to code for primary procedure]).

For the epidural injection, you report code 62310 (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; cervical or thoracic).

Note that when reporting code 62310 with 20552, you need to remember that 62310 has a bundling edit with code 20552. You need to append modifier 59 (Distinct procedural service) identify the separate site for performing the trigger point injection 20552.