Neurosurgery Coding Alert

Answer: For epidural steroid injection, you report code 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; lumbar or sacral [caudal]). For the SI block, you report code 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed). You may append modifier 50 (Bilateral procedures) to 27096 as your physician performs this on both right and left side. It is rare to see these two procedures being done together. The Correct Coding Initiative (CCI) edits show that there is a bundle in codes 62311 and 27096. You may unbundle them with a modifier. If you were to unbundle this pair, you need to append modifier 59 (Distinct procedural service) to 62311, because it is the column 2 code (the component code) to the more comprehensive code, 27096. Note, however, that due to the rarity of these two codes being indicated/performed together, your documentation for proving medical necessity will have to be very clear.