Orthopedic Coding Alert

Question: We would like clarification on how to bill epidural steroid injections to Medicare. We have been getting denials using CPT code 62289* and dx code 724.02. Medicare states these services are not deemed a medical necessity by the carrier. What would deem this to be a medical necessity?

Kelly Poulin
Orthopaedics & Sports Medicine Center, CT

Answer: Medicare considers 62289* (injection of substance other than anesthetic, antispasmodic, contrast, or neurologic solutions; lumbar or caudal epidural [separate procedure]) to be payable for complex regional pain, treatment of severe cancer pain, intractable post herpetic neurolgia, post-traumatic neuropathy, post laminectomy pain with radiculopathy, and pain conditions with the common element of radicular pain which would be caused by nerve root irritation. As such, the diagnosis code 724.02 (spinal stenosis, lumbar region) is not reimbursable by Medicare since it does not specifically define these types of conditions.

Verify with your physician that he has given you the most specific diagnosis possible for that patient. Remember, the condition you are treating with the epidural injection is the pain, not the spinal stenosis.

If spinal stenosis is the most specific diagnosis possible, have your patients sign a waiver so you can collect payment from them if the service is denied.