Pain Management Coding Alert

Published on Thu Apr 03, 2014 PDF

Question: Is there an actual procedure code for a hardware injection? I bill 64999 and submit with the chart notes, then appeal the denial with a letter explaining the procedure. I currently have an insurance company that denied the appeal and is requesting a different CPT® code for a claim correction. 

Part of my letter explaining the procedure states, “spinal fusion hardware inflaming the surrounding area causing the patient’s pain level to be a 6/10. The provider injected Celestone an anti-inflammatory medication around the distal screws of the C1-2 level hardware fusion.” 

The provider is not injecting the epidural space or the nerves but the space surrounding the distal screws. How should we report this? 

Alabama Subscriber 

Answer: You’re wise to submit 64999 (Unlisted procedure, nervous system) with documentation and to be prepared for an appeal since it can be difficult to gain reimbursement for “unlisted” procedures. 

Also note: It’s somewhat unusual for a provider to inject a steroid solely during the hardware block. Instead, a short duration local anesthetic such as Lidociane typically is injected so the physician can determine if the particular retained vertebral screw is the source of the patient’s post-fusion pain. The hardware typically doesn’t cause “inflammation” but the screw may cause pain due to placement near the spinal nerve.

In the appeal, you could include a statement regarding why you’re using the unlisted code. An example would be, “The Instructions for Use of CPT® Codebook clearly state – ‘Do not select a CPT® code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.’ I have found that no CPT® code exists for _____________, therefore I am submitting 64999 (Unlisted procedure, nervous system) for my services provided to your insured.”

It would be helpful to discuss the situation with a representative of the insurer before refiling the claim.