Part B Insider (Multispecialty) Coding Alert

Published on Mon Mar 15, 2004 PDF

Bill for bilateral procedure to maximize your reimbursement

Can you get in trouble for not billing add-on codes? It seems so.
 
A shocking 64 percent of all claims in Indiana for facet joint injection CPT Codes 64470-64476 were filed in error, according to a recent audit by Part B carrier Adminastar Federal. And 54 percent of claims were incorrect in Kentucky. Given the $40,060 overpayment Adminastar discovered, you can expect other carriers to look more closely at these codes.

The problem: providers weren't billing for imaging guidance along with the facet joint injection. You should use either fluoroscopy (76005) or a CT scan (76360) along with the codes, or they'll be denied as not medically necessary, according to the Jan. 29 bulletin. Usually, physicians use fluoroscopy to guide these procedures.

Other reasons Adminastar found for medically unnecessary injections included billing 76005 without the -26 modifier for the professional component; not using primary or add-on codes properly; or submitting documentation for trigger point injections (20552-20553) instead of nerve block injections.

With these codes, 64470 and 64475 are the primary codes for a single level. You bill 64472 or 64476 for each additional level. You should bill one unit per level of either code, regardless of whether the physician performed one or two injections per level.

"If you do [more than one injection] on the same level, you're usually billing left and right," notes Lynn Rogers, office manager with Professional Economics in Bloomington, Ind. So it's important to bill bilaterally. A December coding guidance from Part B carrier Palmetto GBA clarifies that you can bill either 64475 or 64476 using the -50 modifier if you performed the procedure on both the left and right sides of the vertebral column.

Another mistake many providers have made with these codes, according to Adminastar: billing both the -50 modifier and the -LT and -RT modifiers on the same line.

Don't forget: Increase the fee to 150 percent where you're using the -50 modifier, because the carrier won't always increase it for you. And don't add the -51 modifier to 64472 or 64476, because the add-on codes are priced based on the assumption they'll be billed alongside 64470 or 64475 already. The multiple procedures modifier might mislead the carriers into reducing their fees.