Wiki Pain management 64483 and 64484 x2

[jennburgel]

Does anyone know of any medicare chages as to why they are denying the 3rd level for facet injections? Is medicare requireing a modifier now. We are billing 64493, 64494 and 64494 again for the 3rd level. Medicare is only paying the 1sr 2 and denying the 3rd. Any suggestions or info would be helpful.

 

[OCD_coder]

I just checked CMS's Medically Unlikely Edits table and 64494 is only allowed 1 x per DOS.


64492 1
64493 1
64494 1
64495 1

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html

 

[drakena74]

Is it 64483 64484x2 or 64493 64494x2? Codes in title are different then codes in question.

 

[jennburgel]

my appologies i put this up after work. I am looking for 64483,84x2 transforaminal not the facets.

 

[drakena74]

We have the same problem with other insurances & Medicare. As long as there is documentation to back it up, we submit with a -59 modifier on the 2nd 64484 then the lateral modifiers of -LT or -RT and we always get paid.

 

[shenell333@yahoo.com]

Medicare no longer accepts 59 on the third level. You can use 59 when medically necessary to unbundle cci edit...to my understanding you should use modifier 76 on repeat procedure and add any other modifier after that like Lt or Rt etc.....

http://www.cahabagba.com/news/changes-to-modifier-59-important-notice/

 

[drakena74]

I'm in an ASC so are these being performed in ASC/Oupatient Hospital? Or Dr. office?

 

[jennburgel]

ASC. medicare says they need to be billed as units on one line, which is fine if it's only one side, but for the bilat procedures medicare has not accepted the 50 modifier in the past. we just sent in a claim with the 50 mod and 2 units with an adj to the amount and will see what happens. you would think when medicare makes a change like this they would put it out there somewhere. When we called they said this was put in place as of july 1st, but I did not see it anywhere or get any updates from medicare about this change.

 

[jennburgel]

shenello333 where did you find documentation to support the 76? I thought 76 was used when they went back on the same day?

 

[shenell333@yahoo.com]

Check the medicare link on previous post above it will explain further.


http://www.cahabagba.com/news/changes-to-modifier-59-important-notice/

 

[jennburgel]

Thank you we will try that.

 

[shenell333@yahoo.com]

Your welcome!

 

[drakena74]

I'm in Southern California, so I don't know if it's same or different in each regions. We've billed the 64483, 64484 (ea. line) with no modifier other than -LT/-RT and the 2nd 64484 was always denied. so we had to go back & add the modifier, then we were paid.

 

[MarcusM]

ODG offers the following including only two levels in one session....

Criteria for the use of diagnostic blocks for facet “mediated” pain:
Clinical presentation should be consistent with facet joint pain, signs & symptoms.
1. One set of diagnostic medial branch blocks is required with a response of ≥ 70%. The pain response should last at least 2 hours for Lidocaine.
2. Limited to patients with low-back pain that is non-radicular and at no more than two levels bilaterally.
3. There is documentation of failure of conservative treatment (including home exercise, PT and NSAIDs) prior to the procedure for at least 4-6 weeks.
4. No more than 2 facet joint levels are injected in one session (see above for medial branch block levels).
5. Recommended volume of no more than 0.5 cc of injectate is given to each joint.
6. No pain medication from home should be taken for at least 4 hours prior to the diagnostic block and for 4 to 6 hours afterward.