Wiki T12-L1, L1-2, L2-3 Facet joint Injections

[sxcoder05]

Procedure performed: T12-L1, L1-2, L2-3. Codes billed 64490, 64494, 64495. Work Comp is denying 64494 and 64495, only billed with the appropriate initial base code. Operative Note was sent to our auditor; they advise claim was billed correctly and have other clients that have problems getting their claims paid.

Work Comp is stating the following:

So, I confirmed with our coders and nurse and the billing should go like the below,

64490 is a single injection in the thoracic area and they did an injection in T12 then they billed 64494 and 64495 which is an injection in the Lumbar area and they did L1-L2 and L2-L3 they didn’t bill 64491 which is the add on code for 64490 because they only did 1 injection in the thoracic area but they should have billed 64493 is for Lumbar first area then 64494 second area because 64494 and 64495 is an addon code to 64493 and 64495 should not have been billed.

So bill 64490 for the thoracic injection
Then bill 64493 for the first lumbar
And 64494 for the 2nd lumbar injection.

Thoughts please.

 

[lcole7465]

It should be billed as follows:

T12-L1 - 64490
L1-L2 - 64493
L2-L3 -64494

 

[amyjph]

Yes, you can't combine add-on codes from a different spinal region. It would be as suggested above by @lcole7465.
Medicare may have different rules. That may be why the original was coded the way it was, they were not paying attention to the fact that it was WC. You have to know your payer. See MCR LCD example: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=58364&ver=32

 

[sxcoder05]

Per Medicare guidelines, it states for unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and 64494 once. Does work comp have different rules?

 

[amyjph]

Per Medicare guidelines, it states for unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and 64494 once. Does work comp have different rules?

You cannot use CMS rules for Work Comp. Unless the Work Comp carrier specifically states they follow CMS which I have not seen one that does. You have to check your health plan being billed. Always.

 

[sxcoder05]

amyjph you are correct, the remit does not state if follows Medicare guidelines.

Kansas work comp states:

In order to promote correct coding methodologies and to control improper coding leading to inappropriate payments, the Kansas Division of Workers Compensation Schedule of Medical Fees recognizes the 2018 National Correct Coding Initiatives (NCCI) Edits as established by the Centers for Medicare & Medicaid Services (CMS) as the primary standard of reference. The NCCI Edits are not requirements, nor are they mandates or standards; they simply provide advice for correct coding methodologies.

 

[amyjph]

The remit wouldn't necessarily tell you what guidelines they follow. The remit is telling you it was coded incorrectly according to their policy. By linking CMS (which was just an example from CGS which isn't even the MAC in KS anyway), I was pointing out that's probably why it was coded incorrectly to WC, the person was following CMS incorrectly.
NCCI edits have nothing to do with this particular case.
It needs to be done as suggested above by @lcole7465.
There are specific instructions in CPT at the beginning of the code set too. But this WC seems to go against that as well. CPT does state 64494 can be used with 64490, 64493 in a parenthetical note. As well as, 64495 can be used with 64493, 64494. WC makes up it's own rules sometimes though, as do some health plans. Or, maybe they are just wrong. You would have to get more info on their policy.