Balance billing for unbundled procedures

stonecm

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Our Dr. is not in network with any insurance except Medicare. The coder before me reported:
62310
64479
72275
77003

I know 77003-26 can be reported with 62310, but I would not report 72275 because fluoro is included with the injection codes and a formal epidurogram wasn't performed. *Imaging guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of 64479-64484. Imaging guidance and localization are required for the performance of 64479-64484*

BLue Shield insurance paid on the 64479 and 72275 but did not pay the other lines stating they were bundled. Our collector told me that I can balance bill for the other service becuase we are out of network, but I didn't think we could balance bill the patient for procedures that were unbundled. Our collector insists that unbundling doesn't apply to out of network claims, but I wanted to make sure before I bill the patient.

Any advise is greatly appreciated!
 

dwaldman

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Code 64479 is mutually exclusive to code 62310 but a modifier is allowed in order to differentiate between the services provided.

Code 77003 is a component of Column 1 code 64479 but a modifier is allowed in order to differentiate between the services provided.

Above is from NCCI for these codes: 62310 64479-59 77003-59 The 59 modifier could be applicable if the interlaminar cervical epidural (62310) with fluoroscopic guidance (77003) was performed at a separate level as fluroscopy guided transforminal epidural (64479) in the cervical region. If it appears the note does not support that these procedure were performed at separate levels then it would not be appropriate to make the patient responsible for the balance. And going into the procedure, the precert/scheduling would need to educate the physician a interlaminar and transforminal at the same encounter is recipe for denial when you are seeing mutually exculsive edits with higher RVU code being bundled. I personally would not bill the patient and be happy they paid the transforminal but review that there was actually an diagnostic epdurography performed and if not, then at this point 72275 would have be refunded to the carrier.

Typically CPT 72275 is not going to be reported. I personally have never bill 72275 because although they perform epidurograms for assistance in some procedures the purpose is not for creating formal contrast study report.

Below is an example from the AMA CPT Network where they are not recognizing in the same spinal region a transforminal and interlaminar approach, although it is felt that 59 modifier could represent separate levels in the region from an NCCI perspective.


Surgery

Nervous System

Question

In which instances would it be appropriate to report codes 64483 and 62311 together?

Answer

Code 62311, Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal), describes epidural or subarachnoid injections of non-neurolytic substances including opioids, steroids, antispasmodic, and anesthetic substances, and does not differentiate between types of substances injected, but rather focuses on the route of administration (ie, single injection [not via indwelling catheter] versus continuous infusion or intermittent bolus via catheter). However, it is important to recognize that code 62311 excludes injection/infusion of a neurolytic substance, which is reported by codes 62280-62282. Therefore, based on the above information and in answer to your specific question, since code 62311 includes the injection of non-neurolytic substances, it would not be appropriate to separately report code 64483, Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level.
 
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