Coding Compliance: OIG eyes transforaminal epidural injections

Published: 22nd March 2010
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The Office of Inspector General (OIG) Work Plan for 2010 includes a detailed look at Medicare payments for transforaminal epidural injections. The Work Plan states, "We will audit Medicare claims to find the appropriateness of Medicare Part B payments for transforaminal epidural injections."

Avoid the OIG crosshairs by assuring that your pain management specialist documents each procedure efficiently. Carry out these steps to count the levels and assign the appropriate codes.

1. Understand the term 'Transforaminal'

Joanne Mehmert, CPC, CCS-P, President, Joanne Mehmert and Associates in Kansas City, Mo says, "Physicians often apply transforaminal epidurals laterally in coordination with the selected neuroforamen under fluoroscopy". Once there, the physician then performs an injection at the nerve root area which helps in relieving the patient's pain. The medication then goes into the anterior epidural space, and as it exits the spinal cord it helps in"bathing" a specific spinal nerve.

CPT includes four codes to represent transforaminal epidural injections, which you choose between based on the injection site and number of injections:

• 64479 - Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level (2009 national average Medicare reimbursement of $114.69 facility/ $253.55 non-facility)

• +64480 - ... cervical or thoracic, each additional level (List separately in addition to code for primary procedure) ($75.02 facility/$127.68 non-facility)

• 64483 - ... lumbar or sacral, single level ($100.99 facility/$246.70 non-facility)

• +64484 - ... lumbar or sacral, each additional level (List separately in addition to code for primary procedure) ($63.84 facility/$125.15 non-facility).

Procedure note: Even though you report the same codes, a transforaminal injection is different from a selective nerve root block (SNRB). With SNRB, your provider injects right next to the nerve root where the nerve exits the foramen. This injection occurs outside the spine, which differentiates it from a transforaminal. The coders often interchange the terms; as such knowing the difference in technique would be helpful in understanding your physician's documentation.

2. Be attentive while counting levels

Though the transforaminal injection descriptors are specifically for spinal levels, your physician actually aims at the space between vertebrae or the interspace. This difference in the code terminology and the procedure can confuse the coders, so make up your chances with the OIG by understanding well how to count levels correctly. Keep in mind that you're counting interspaces, not the vertebral bodies.

Hint: When the provider injects the needle through the foramen into the interspace between the discs, that is a spinal level and you should code with 64483. And If your provider injects another needle into the next interspace, consider that as a second spinal level and code report +64484 along with 64483.

Point to note: If your provider inserts the needle at both sides of the same level, don't report for separate levels instead report a bilateral injection. Mehmert explains, "Even though payers ask for various claim formats, that doesn't imply that each side at the same spinal level is a different level".

Next step: Check your payer's guidelines for bilateral reporting. Dawn Shanahan, CPC, supervisor of coding, Florida Gulf to Bay Anesthesiology Associates in Tampa states "Most of the insurance firms I deal with asks to use the modifier 50 (Bilateral procedure) and file on one line". In such cases, code a bilateral transforaminal injection as 64483-50 rather than 64483 with +64484.

Codes 64479-64484 have a bilateral surgery indicator of "1" and they are considered as unilateral procedures and most of the insurers will pay 150 percent for a bilateral block from this code family. Include modifier LT (Left side) or RT (Right side) when reporting a unilateral block with 64479-64484, so that the payer fully understands the procedure.

3. Check if Fluoroscopy Code Applies

Mehmert says, "Though it is not specifically stated in the CPT that fluoroscopy must be used here to report the codes but it is a universal standard to use fluoro." Report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) in addition to the procedure code when your physician uses fluoroscopic guidance.

"There needs to be a mention of the fluoroscopy in the documentation as well as a hard copy of the film in the patient's medical record," Shanahan says. "My physician mentions the use of fluoro as well as the type and amount of dye used or if the dye was not used and why."

Know what guidelines says: Know your payers well as the insurance companies have different guidelines regarding levels that can be injected during the same encounter, the time between procedures, and other parameters. "For instance, Blue Cross/Blue Shield of Florida, states that a patient can receive diagnostic injections every week but the therapeutic injection time is no sooner than eight weeks," Shanahan says.

However other payers have policies that deny treatment as unreasonable or medically necessary when your physician administers combinations of epidural, facet, lumbar sympathetic, or bilateral sacroiliac joint blocks on the same day.

CPT includes many subordinate notes explaining when you can or cannot report 77003 with various injection procedures. In tranforaminal epidural coding none of the notes restricts you from reporting 77003 with transforaminal epidural codes 64479-64484. As your physician needs to use fluoroscopy or a CT scan to confirm needle placement in the transforaminal epidural space, it might raise payer eyebrows if you don't report 77003 with the injection codes.

Leigh Delozier, CPC has been writing medical coding articles for anesthesia, pain management, orthopedics, neurosurgery, and other specialties since 1999. Read more of her specialty-specific coding advice on

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