Radiology Coding Alert

Consider factors such as site, level, and use of imaging when determining code.

In Volume 20, Number 11 of Radiology Coding Alert, you got an in-depth glimpse into the world of transforaminal injection and paravertebral block coding. While that knowledge will go a long way in preparing you for your next spinal injection report to code, the buck does not stop there. In addition to those two sets of spinal injections, there are two additional sets that you’ve got to stay on top of.

While the codes’ parenthetical notes and National Correct Coding Initiative (NCCI) edits might offer you some guidance in your code selection, these sources of information don’t often tell the whole story. That’s why it’s important to stay up to date on the information the CPT^® Assistant has to offer on the subject.

Dive in for a comprehensive overview of the coding processes behind paravertebral facet joint and interlaminar epidural/subarachnoid injection coding.

Identify 6449X, 6232X Injection Code Sets

Before getting into the specifics, you’ll want to lay out the respective codes from each of these two code sets. Compare these codes (and subsequent notes) with the code sets referenced in Radiology Coding Alert Volume 20, Number 11.

First, have a look at the code’s you will use to report paravertebral facet joint injections (64490-+64495):

• 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
• +64491 — … second level (List separately in addition to code for primary procedure)
• +64492 — … third and any additional level(s) (List separately in addition to code for primary procedure)
• 64493 — … lumbar or sacral; single level
• +64494 — … second level (List separately in addition to code for primary procedure)
• +64495 — … third level (List separately in addition to code for primary procedure).

Next, you’ll examine the code set used to report interlaminar epidural (or subarachnoid) spinal injections (62320-62327):

• 62320 — Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
• 62321 — … with imaging guidance (ie, fluoroscopy or CT)
• 62322 — … lumbar or sacral (caudal); without imaging guidance
• 62323 — … lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)
• 62324 — Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
• 62325 — … with imaging guidance (ie, fluoroscopy or CT)
• 62326 — … lumbar or sacral (caudal); without imaging guidance
• 62327 — … lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT).

Consider These Two Operative Reports

The best way to distinguish these two therapeutic services is by comparing and contrasting operative reports. First take a look at a sample portion of an operative report for a fluoroscopic-guided cervical facet joint injection:

• “1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C4-5 facet joint under fluoro­scopic control. Positioning was checked and 0.2 mL of dye was injected. Acceptable dye pattern was seen. Subsequent 1 mL of a mixture of 0.5 mL of 1% lidocaine and 0.5 mL of Celestone was injected after aspiration and the patient was monitored. Needle was removed and same procedure carried out on the other side.”

As you can see, you have all the information you need in order to code this as 64490. First, you identify the needle injection of the C4-C5 facet joint. Next, you will confirm the fluoroscopic (or computed tomography (CT)) guidance. If the provider directs the injection toward an additional cervical level, you will report +64491.

Now, have a look at a sample portion of an operative report for an interlaminar epidural spinal injection:

• “The cervical interspinous level of injection is identified and marked. Local anesthetic is injected into the skin and subcutaneous tissues. The injection needle is carefully directed into the epidural space. Care is taken to avoid damaging any nerve roots or the spinal cord. Since image guidance is not used, loss of resistance with air and/or normal saline is used to ensure proper identification and placement of the needle in the epidural space.”

This report is as straightforward as that of the paravertebral facet injection. As long as you’ve got the cervical epidural (or subarachnoid) space documented within the report, you’ve only got two other measures to confirm before coding. First, you want to determine whether or not the provider utilizes imaging guidance. In this example, there is no documentation of fluoroscopic or CT guidance. Lastly, the mechanism by which the provider injects the therapeutic substance will determine your CPT^® code. Since the provider uses a needle in this sample report, you will rely on code 62320 as your final answer. If the provider opts to use an indwelling catheter instead of a needle, you will refer to the 62324-62327 code set.

Refresher: Make sure you understand the differences between an indwelling and a non-indwelling catheter. “The placement of an indwelling catheter involves the slow infusion of medicine over a period of time,” explains Barry Rosenberg. “On the other hand, a non-indwelling catheter involves a single injection. Rarely, if ever, will you see the use of a non-indwelling catheter for a single injection when a needle can be incorporated instead,” says Rosenberg.

Note 2 Sets of CPT^® Assistant Instructions

Finally, you will want to make sure you adhere to these code-specific guidelines laid out by the CPT^® Assistant. First, the May 2012; Volume 22: Issue 5 CPT^® Assistant outlines how you should address an injection of spinal hardware:

• “There is no specific CPT^® code for the injection of spinal hardware. CPT^® code 64999 (Unlisted procedure, nervous system) would be most appropriate to describe the injections for pain performed outside the foramen.”

Finally, make sure you have a firm grasp on each of the four spinal injection codes’ bilateral indicator status. For example, code set 62320-62327 has a bilateral status indicator of “9,” which means that the bilateral status concept does not apply to these codes. This makes sense since the interlaminar epidural and subarachnoid spaces are not bilateral.

“Generally, the status indicator of 9 means that the concept doesn’t apply to that specific body part,” says Leslie Johnson, CPC, coding and auditing consultant at Oasis Medical and Surgical Wellness Group, LLC, in Glen Rock, New Jersey. “When it comes to the bilateral status indicators a part of the body or anatomic region has to have a right side and a left side. The spinal cord only has no right or left side as it runs inside the spine. When nerve blocks are given, they physician administers them through the spinous ligaments into an epidural or subarachnoid space. There’s no ‘right’ or ‘left’ to the epidural or subarachnoid space,” Johnson explains.

On the other hand, code set 64490-+64495 has a bilateral status indicator of “1,” which means that, according to the January 2016; Volume 26: Issue 1 CPT^® Assistant, “they are considered ‘unilateral’ procedures and the 150% payment adjustment for bilateral procedures applies. The CPT^® Assistant goes on to advise that, “when injecting a nerve root bilaterally, file with modifier -50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier -LT or -RT.”