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64493 with 27096

  1. #1
    Arrow 64493 with 27096
    Medical Coding Books
    My physician performed a 1. Left L4-L5 and L5-S1 interfacet joint injection utilizing fluoroscopy and 2. Left SI joint injection utilizing fluoroscopy for guidance. But, Encoder Pro states that 27096 bundles with 64493 and no modifier is allowed. Does anyone have any suggestions as to how this should be coded, then?
    Thanks, in advance, for all of your help! (Please see the procedure note below.)

    The patient was identified. A written and verbal informed consent was obtained. Vital signs were evaluated and monitored throughout the procedure. The patient was presented to the fluoroscopy suite and positioned prone. The skin overlying the lumbar and sacral region was thoroughly cleansed with Betadine solution and draped in a sterile fashion. IV access was obtained in the upper limb. Upon initiation of the procedure, due the patient's blood pressure and desire to minimize discomfort, the patient received 6.25 mcg of fentanyl IV push. Utilizing fluoroscopy for visualization, we viewed the left L4-L5 and L5-S1 facet joints with AP and oblique views. A 27-gauge 1.5-inch needle was utilized to administer buffered 1% lidocaine to produce a subcutaneous wheal overlying these two facet joints on the left. Once completed, 22-gauge 3.5-inch spinal needles were utilized as guided by fluoroscopy to penetrate the skin, subcutaneous, and intramuscular tissue towards these joints. AP, lateral, and oblique views were utilized to guide the placement of the needles. Once it was determined that we were within the joints, the patient received 0.25 mL of contrast, Omnipaque 180, following negative aspirations for blood and/or CSF. Once contrast confirmed the proper location and the absence of intravascular injection, the patient received 0.5 mL of injectate at each of the facet joints following negative aspirations for blood and/or CSF. Injectate included a mixture of 1.5 mL of 0.75% Marcaine and 1.5 mL of betamethasone (6 mg/mL). The stylets were replaced within the needles, and the needles were withdrawn. The area then overlying the lumbar and sacral joint on the left was exposed with fluoroscopic imaging. Palpation over the painful area confirmed as site of pain as visualized with fluoroscopy. The targeted area of skin overlying the left sacroiliac joint was identified. A 27-gauge 1.25-inch needle was utilized to administer 1% buffered lidocaine to produce a subcutaneous wheal overlying the one-third caudad portion of the left SI joint. A 22-gauge 3.5-inch needle was then guided by fluoroscopy towards the left SI joint. Penetration within the space was difficult, likely based on sclerosis and calcification of this actual anatomic joint space in this patient of age. Once it was felt that we were in a close location, the patient received 0.25 mL of contrast following negative aspiration to confirm the absence of intravascular injection. Contrast was Omnipaque 180. At this point, the patient received 1.5 mL of injectate. Injectate included a mixture of 2 mL of 0.75% Marcaine and 1 mL (6 mg/mL) betamethasone. The stylet was replaced in the needle, and the needle was withdrawn. Identical format was carried out to a more medial and cephalad direction for the left SI joint. Again, contrast was used to confirm the absence of intravascular injection, and the patient received the remainder of the 3 mL of injectate following negative aspirations for blood. The area was thoroughly cleansed. Adhesive bandages were placed, and the patient was returned to the recovery area. There was no evidence of intravascular or intraneural injection. There were no complications with the procedure. She was stable and ambulatory upon discharge. Her preprocedure VAS was a 7. Her postprocedure VAS was a 6. We will contact her within 24 hours to further evaluate her response to today's procedure.

    Thanks, again!

  2. #2
    64493 has an RVU of 2.76
    27096 has an RVU of 2.08

    In the mutually exclusive edit table, 64493 is a column two code to column one code 27096 and modifier is not allowed

    This same question arises if 64483 and 62311 is performed at the same level due to their mutually exlcusive status.

    Below is from the CPT Network

    ".......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"

    One would think due to the fact that 64483 has the higher reimbursement, why can't 64483 be reported even though from NCCI standpoint it is column two. It could be questioned can you bill the column two code instead of the column one code when dealing with a mutually exclusive edit pair.

    I have looked thru chapter one of the NCCI policy manual, it simply says the code pair can not be reported together. It does say that you have to report the column one code with a mutually exclusive edit pair. Since with your example and other mutually exclusive edits the column two that they bundle has the higher RVU and actually represents the more "comprehensive" service that was provided. Without any documentation within the NCCI policy stating you have to report the column one code, I feel comfortable stating that though you will not be able to report both service, you are not obligated with a mutually exclusive edit to report the column one code.

    This is the statement within the manual that supports my interpretation.

    "In the latter type of edit the code pair edit simply represents two codes that should not be reported together"

    From the NCCI Policy Manual

    The CMS developed the NCCI to prevent inappropriate payment of services that should not be reported together. There are two NCCI edit tables: “Column One/Column Two Correct Coding Edit Table” and “Mutually Exclusive Edit Table”. Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment. (NCCI-associated modifiers and their appropriate use are discussed elsewhere in this chapter.) All edits are included in the “Column One/Column Two Correct Coding Edit Table” except those that are based on the “mutually exclusive” (Chapter I, Section P) and “gender-specific” (Chapter I, Section Q) criteria in which case the edits are included in the “Mutually Exclusive Edit Table”.

    When the NCCI was first established and during its early years,the “Column One/Column Two Correct Coding Edit Table” was termed the “Comprehensive/Component Edit Table”. This latter terminology was a misnomer. Although the column two code is often a component of a more comprehensive column one code, this relationship is not true for many edits. In the latter type of edit the code pair edit simply represents two codes that should not be reported together. For example, a provider should not report a vaginal hysterectomy code and total abdominal hysterectomy code together.

  3. #3
    I have read that as of July 1, 2011 the edit for 64493 and 27096 has been deleted and the deletion will be retroactive to the implementation of edit, April 1, 2011.

    Does anyone know if Medicare going to do an adjusted of the claims that have been denied? I called to WPS and she really didn't give me an answer.

    Missy Heuer CPC, CIRCC, CANPC

  4. #4
    WPS Medicare has email function under their "contact us" section. I would email your question and they will have someone research it and get back with you. I agree that running these thru a CCI check they don't show that they are bundle with verison 17.2 but with 17.1 they are. It interesting that they have changed this.

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