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1 Report therapeutic hip injection under fluoro with and Use the following Q & A to determine how to bill imaging when you provide a hip injection. Question: How do you report an injection of the hip under fluoroscopy? Do you use the arthrogram codes? Answer: No. In fact, the AMA recently clarified this issue. If you are injecting a steroid or anesthetic agent into the hip joint under fluoroscopic guidance, you would report for the major joint injection and for the use of the fluoroscope for needle guidance, according to the June 2012 CPT Assistant. Note that this guidance updates some inaccurate coding advice issued in the February 2012 CPT Assistant, which you should now set aside. The decision to report versus a hip arthrogram comes down to intent and by the way, the amount of contrast injected doesn t make a difference, the AMA says. If the contrast is injected only to confirm needle position within the joint, the quantity [of contrast] does not matter, according to the June 2012 CPT Assistant. If instead the contrast is injected with the intention to outline the joint surface to perform a radiographic arthrogram, then it is an arthrogram even if only a few ccs of contrast material are injected. That busts the old myth that you could tell whether an injection was a diagnostic radiological test, such as an arthrogram, versus a therapeutic injection by how much contrast or dye the physician used. The AMA clarifies that physicians instead must signal the intent of the injection treatment or diagnostic in their procedure notes. In addition, to bill an arthrogram, your documentation should include radiographic hard copies of the arthrogram in multiple views and a separate radiological interpretation and report, the AMA instructs (CPT Assistant, July 2008). Code a hip arthrogram using either when no anesthesia is used or when the injection is done under anesthesia. In each case, you d report radiological supervision and interpretation with Sacroiliac Joint Injections y Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed. Description of Procedure Under CT or fluoroscopic guidance, a needle tip is fed into the caudal aspect of the articular joint between the sacrum and iliac. The injection may be diagnostic (contrast material or anesthetic) or therapeutic (anesthetic or steroid). If the injection is performed without CT or fluoroscopic guidance, report a trigger code injection. y Under CT or fluoroscopic guidance, a therapeutic or diagnostic agent is injected into the sacroiliac joint. y CT or fluoroscopic imaging guidance is required to confirm the intra-articular needle positioning. This code reports both the injection and the imaging guidance. y A therapeutic or diagnostic procedure is performed. 80 Pain Management Coding Answers, 2016

2 Sacroiliac joint disorders create a unique set of diagnostic and treatment challenges. These joints, which hardly move at all, are formed by the sacrum, the spade-shaped bony structure at the bottom of the spine, and the iliac bones of the pelvis. Humans are especially prone to sacroiliac joint derangement because the entire spine and all its related structures rest on the sacrum. These two joints support the whole weight of the body from the waist up. The sacroiliac joint is like a complex jigsaw puzzle. When the pieces don t fit together perfectly, the result can be a very uncomfortable form of low back pain. Sacroiliac disorders are especially challenging to diagnose because patients do not complain of the usual neurological symptoms. There is no numbness, tingling or weakness. SI joint injections may be diagnostic or therapeutic. One or several joints may be injected depending on location of the patient s usual pain. If the first injection does not relieve the pain in about two weeks, another injection may be scheduled. The procedure is typically done under local anesthesia. Some patients may also receive intravenous sedation and analgesia, although CMS says general anesthesia or MAC are rarely, if ever required for the procedure and may, in fact, provide false-positive results. The procedure: In a typical joint injection, the patient is placed face down on the x-ray table so the physician may visualize the SI joints using x-ray guidance. The skin on the low back is sterilized and treated with a numbing agent. Once the numbing medicine has become effective, the physician uses x-ray guidance to direct a small needle into the joint. A small amount of contrast is injected to insure proper needle position inside the joint space. Finally, a small mixture of numbing medicine and an antiinflammatory agent is injected into the patient s joint. Tip: As of Jan. 1, 2012, imaging services are bundled into this procedure. S/I Joint Q & A Question: Based on the new instructions for S/I joint injections, our physicians believe they can bill the injection and report imaging separately if they use ultrasound. Is this true? Answer: That isn t the correct interpretation of the parenthetical notes for 27096, but this is a good opportunity to show your doctors how to read the CPT manual. The first note states, you must bill when the doctor doesn t use CT or fluro imaging for this service. Your physicians may have read that and thought that because CPT doesn t specifically state not to use ultrasound with that code, ultrasound guidance is reportable. Your doctors also should understand that when reading the CPT manual, they may need to look beyond the guidance for a specific code. Had your doctors also reviewed (ultrasonic guidance for needle placement), they d see it now states you cannot report this service with Finally, they should understand that unlisted ultrasound procedure code isn t an option for this service because specific codes already describe the imaging service. Epidural Injections y Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic Copyright 2015 DecisionHealth CPT 2014 American Medical Association. All rights reserved. 81

3 y Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) y Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic y Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Description of Procedure The physician injects therapeutic or diagnostic fluid into the fluid-filled sac that surrounds the spinal cord (the epidural space) of the cervical or thoracic spine. The physician may first inject contrast into the epidural space to confirm location, then perform the injection under separately reported fluoroscopic guidance. Alternately, a catheter may be placed for the infusion of the diagnostic or therapeutic fluid. If a catheter is inserted, it is removed within the same calendar day. y The epidural spine is injected at the cervical or thoracic level to reduce pain, spasm, or inflammation. y The drug may be administered by needle or catheter. If a catheter is used, it remains in place for less than a single calendar day. y The injection is not a neurolytic substance. y Multiple injections on the same side at the same level are reported only once. y Injection of contrast is included in this procedure. Description of Procedure The physician injects therapeutic or diagnostic fluid into the fluid-filled sac that surrounds the spinal cord (the epidural space) or the subarachnoid space of the cervical or thoracic spine. The physician may first inject contrast into the epidural or subarachnoid space to confirm location, then insert a catheter under separately reported fluoroscopic guidance. Intermittent or continuous medication is fed through the catheter, which remains in the patient for more than one calendar day. y A catheter is placed in the epidural spine at the cervical or thoracic level to reduce pain, spasm, or inflammation. y The drug may be administered by catheter, which remains in place for more than a single calendar day. y The injectoin is not a neurolytic substance. 82 Pain Management Coding Answers, 2016

4 y Multiple injections on the same side at the same level are reported only once. y Injection of contrast is included in this procedure. y Daily hospital management of continuous epidural or subarachnoid drug administration is separately reported with The most common approach for epidural injections, the translaminar approach, requires a pain management physician to advance a needle directly into the epidural space in the area of the suspected inflammation. Once the physician confirms that the needle tip is in the epidural space, the medication is released so that it fills the epidural space in that part of the spine and bathes the diseased nerve root. When this method is performed in the lumbar region, it is referred to as a lumbar epidural steroid injection (LESI). Injections of steroids can also be performed in the epidural space in the cervical or thoracic spine. However, the higher the injection spot is on the spine, the greater the risk of complication. Steroid injections do not bring immediate relief, but their effect should be noticeable after one day. The procedure may be repeated after a couple of weeks if the patient responds positively to the injection. While it is not uncommon for a patient to get as many as three injections in a series, it is considered inappropriate to keep repeating the procedure if the patient does not experience increased pain relief with each subsequent injection. Consequently, most payers will not reimburse a physician for more than three injections in a six-month period. Typical documentation The note that follows is an example of a typical dictated report for a caudal epidural steroid injection (62311). Dictated Report: Caudal Epidural Steroid Block PREOPERATIVE DIAGNOSIS: Anorectal pain POSTOPERATIVE DAIGNOSIS: Anorectal pain PROCEDURE: Caudal epidural steroid block PROCEDURE IN DETAIL: Following a pre-block interview and vital signs assessment, the risks and benefits of the procedure were explained to the patient. The patient did consent to the procedure. The patient also was subsequently brought to the block room and placed in a comfortable prone position. The lumbosacral area was prepped with Betadine and draped in a sterile manner. Using fluoroscopy guidance, the skin over the sacrococcygeal membrane was anesthetized with lidocaine 0.5% for a total of 2 ml. Using 22-gauge 1 1/2-inch needle, the caudal epidural space was accessed through the sacrococcygeal membrane. Confirmation of location of needle was done with the injection of radiopaque dye and following the spread in both AP and lateral projections. After negative aspiration, a total of 25 ml lidocaine 0.5% with 40 mg Depo-Medrol was injected in the caudal epidural space. Copyright 2015 DecisionHealth CPT 2014 American Medical Association. All rights reserved. 83

5 The patient tolerated the procedure well with no motor or sensory manifestations post procedure. The vital signs were post procedure were stable. Typical diagnoses Caudal epidural blocks are indicated for various pathologies of the lower spine, all associated with extremity or back pain, including: y Herniated disk y Scoliosis y Slipped disk y Spondylosis y Spinal stenosis Some of the most common ICD-9 diagnosis codes you ll see for caudal epidural blocks are those for spinal stenosis (723.0, 724.0x) and slipped disks (722.0, 722.1x). You should always check with your own Medicare carrier and private insurers to verify what diagnoses they expect for caudal injections. Medicare restores fees for epidurals but removes separate imaging payment Medicare s decision on epidurals in the final 2015 Medicare physician fee schedule could be good or bad news, depending on how you look at it. CMS kept its promise to return the RVUs for epidurals to their 2013 levels. But it also went ahead with its plan to bundle fluoroscopic imaging into the services. The following chart compares the payments for epidurals in 2013, 2014 and Code Short descriptor 2013 a 2014 b Inject spine cerv/thoracic $ ($349.07) $ ($201.68) $ Inject spine lumbar/sacral $ ($309.26) $ ($199.89) $ Inject spine w/cath crv/thrc $ ($340.57) $ ($202.40) $ Inject spine w/cath lmb/scrl $ ($271.84) $ ($205.98) $ All payments are national, participating, non-facility. a The amount in parentheses shows the payment plus fluoroscopic guidance $95.94 b The amount in parentheses shows the payment plus fluoroscopic guidance $90.99 In the 2014 physician fee schedule, CMS lowered the practice expense for the injections because a large part of the expense was the fluoroscopy room, which providers no longer need, unless they re in a state that requires a shielded room. But the change was sudden and not included in the proposed 2014 fee schedule. So for 2015, CMS raised the practice expense but will require providers to pay for the fluoroscopy. And that won t be the end of the epidural saga. They re planning to address this in the 2017 RUC cycle. 84 Pain Management Coding Answers, 2016

6 Update staff, templates; watch payers Make sure administrative and clinical staff know they should not submit the imaging service with epidural services. If your software system is keyed to include the imaging code when someone enters an epidural, ask your vendor to turn that function off, at least for Medicare patients. You should also expect denials if you submit imaging codes such as epidurography with epidurals. According to a CMS official, the new bundling policy applies to all imaging services. Finally, watch your private payers. This policy applies only to Medicare services and while private payers often follow the agency s lead, you may be able to negotiate payments for the imaging service. Managed care contracts may also be open to negotiation, but it won t be easy. If the payer follows Medicare guidelines, the only recourse you would have is to try to carve out the epidurals. When the contract specifically states that they follow the Medicare documentation guidelines, then all bets are off. You may be able to use the fact that CMS has placed the epidural codes on the list of potentially misvalued codes for review by the RUC in order to attempt to carve them out. Transforaminal epidural injections y Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level y Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) y Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level y Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) Description of Procedure An anesthetic or steroid is injected into the epidural space by inserting s small needle through the intervertebral foramen under fluoroscopic or CT guidance. A vertebra in the neck or thoracic back is treated. y A transforaminal epidural injection enters the epidural space in a vertebra of the neck or upper back through the intervertebral foramen. y This procedure treats neck or back pain. y Do not use this code if the injection is a translaminar epidural or paravertebral facet joint nerve injection. y Imaging guidance is included in this procedure. Copyright 2015 DecisionHealth CPT 2014 American Medical Association. All rights reserved. 85

7 Description of Procedure This add-on code reports injection of an additional site in the cervical or thoracic spine for transforaminal epidural, including fluoroscopy or CT guidance. y A subsequent transforaminal epidural injection enters the epidural space in a vertebra of the neck or upper back through the intervertebral foramen during the same encounter as the first. y This procedure treats neck or back pain. y This code is not appropriate for transforaminal epidural injection with ultrasound guidance. See 0229T. y Do not use this code if the injection is a translaminar epidural or paravertebral facet joint nerve injection. y Imaging guidance is included in this procedure. While standard epidural steroid injections involve a needle inserted between the spinous processes of two vertebrae, transforaminal epidurals make a lateral injection (from the side) that targets the nerve root as it projects through the foramen. Because such an approach allows for a very selective targeting of a specific nerve root, it is often referred to as a selective nerve root block (SNRB). Although these selective nerve root blocks have therapeutic value, the blocks usually are performed as diagnostic blocks to confirm the source of a patient s pain. They are especially effective when the pain is limited to one side of the body. Students of pain management often ask why a physician would choose to perform a selective nerve root block instead of a traditional epidural injection. There are various indications, but the most common is the need to isolate a specific nerve root or side of the spine as the cause of the patient s pain. In many cases, these diagnostic blocks are performed at the request of a spine surgeon who needs confirmation of the origin of a patient s low back pain before making the decision to perform surgery. It is considered inappropriate to perform a selective nerve root block without fluoroscopy. In fact, most pain physicians will argue that it is impossible to identify the nerve root without the injection of a small amount of dye into the membrane that surrounds the nerve root. When properly placed, the dye traces up the nerve root into the epidural space and the relevant anatomy is clearly visible on the fluoroscopic display. Sometimes a physician may decide to perform selective nerve root blocks at multiple levels. These allow the pain physician to determine if multiple nerve roots are contributing to the patient s pain. Lumbar transforaminal epidural injection, spine Procedure Left L5 transforaminal epidural steroid injection under fluoroscopic guidance (64483) Indications Back and left lower extremity pain related to post laminectomy pain syndrome 86 Pain Management Coding Answers, 2016

8 Contraindications There were no contraindications Informed consent was obtained and placed into the procedure chart before the patient was brought into the Ambulatory Surgical Center. Description of procedure The patient was placed prone on the fluoroscopy table. The lumbar spine was prepped using triple Betadine wash. The left L5 pedicle was identified under slight oblique fluoroscopic guidance. A 22-guage, 5 inch short bevel spinal needle was advanced carefully towards the 6 o clock position at the left L5 pedicle and the patient felt paresthesia into the left lower extremity and 1 cc of Isovue was injected with good fluoroscopic pattern. However, the needle had to be manipulated on two or three occasions in order to correctly placing into the epineural sheath. The patient did feel a paresthesia when appropriate needle placement was made. 1 cc of Isovue was injected under good fluoroscopic pattern without vascular uptake. A total of 4 cc was then injected, including 3 cc of betamethasone, 1 cc of preservative-free lidocaine. The patient tolerated the procedure well. The needle was removed and patient was transferred to the recovery room in good condition. No complications were noted. Epidural Q & A Here s a brief description of a cervical injection. See if you can come up with the proper billing answer from the choices listed below, then check below to see if your answer matches up with ours. With laminar approach, a catheter is steered thru the epidural space, until the final position is reached at the medial neuroforaminal area/zone of the desired level. Medication is injected. Given this is a laminar approach, using a catheter and with a single shot of medication, which is the appropriate code to bill for this service? a b c d The correct answer is c Reporting a transforaminal is dependent on where the needle/catheter is placed. Transforaminal The tip of the injecting needle or catheter is directed under radiographic image guidance with either computed tomography, fluoroscopy, or ultrasonic guidance for placement at the neuroforamen. Contrast is utilized to verify correct needle placement, determine abnormal filling patterns consistent with foraminal, lateral recess or nerve root pathology and to identify unwanted vascular or intrathecal uptake. Appropriate placement allows for the precision placement of the substance(s) injected at the foraminal and lateral recess regions or for blocking a specific nerve root. Contrast that with an epidural, which is coded based on placement of the needle and whether or not it is an injection or catheter: Copyright 2015 DecisionHealth CPT 2014 American Medical Association. All rights reserved. 87

9 Epidural An epidural injection is an injection of medication into the epidural space of the spine. Local anesthetic, a steroid or a combination of both can be used. Therapeutic interlaminar/translaminar or caudal epidural injections and infusions of opioid, local anesthetic, or other medications may be used for the treatment of acute and chronic pain or cancer pain. As you can see above, the placement must indicate placement at the neuroforamen. Based on two carrier policies the documentation for an epidural would indicate injection of medication into the epidural space. This can be done with a single shot (62310 or 62311) in which you would expect to see medication of a local anesthetic, steroid or a combination of the meds. On the other hand, a continuous infusion (62318 or 62319) usually contains opioids for acute pain management. The continuous can also be performed with a local anesthetic or other medications, but is not done with steroids. The catheter is not the key in determining continuous. It is whether the catheter is left in place and the documentation indicates a long term continuous infusion. Coccyx Injections Injections into the coccyx can be billed using several different codes, depending on where and why the injection took place, says the American Medical Association. However, disputes over whether the coccyx is a joint have led to a myriad of coding suggestions from coders and consultants. The coccyx, says the AMA, is not a joint but a fused bone, commonly referred to as the tailbone. The area typically injected, however, is the sacrococcygeal joint, between the coccyx and sacrum, which, depending on the patient, may be either a fused joint or a non-fused segment. Coccyx injections currently have no specific code, which has led to a Cinderella-like search among coders and consultants for the best-fitting code. Both the dispute over whether the coccyx is a joint or not, and the multiple scenarios for which a coccyx injection could be necessary, coders have used various procedure codes, as demonstrated in the chart below. Coding options Even though coccyx injections don t have a specific procedure code, you have several viable coding options, including: Code Description Injection; tendon sheath, ligament, ganglion cyst Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst Unlisted procedure, pelvis or hip joint Unlisted procedure, nervous system In a May 2002 letter to a consultant, the AMA advised code (unlisted procedure, pelvis or hip joint) for an injection to treat coccyx edema, or swelling. This advice caused a minor furor among coders, some of whom state the AMA s advice is illogical, especially when more specific and higher paying codes already exist. The AMA has said codes 20600, 20605, and could all work for coccyx injections, though is not appropriate without specific information concerning nerves. Before deciding which code works best, coders should ask: Is this injection for pain? Is the injection into the paravertebral facet joint or facet joint nerve? Is it actually a transforaminal epidural injection? It all comes down to the intent of the injection. For example, code might not work because it is intended for injections into a tendon, not through a tendon. If, however, the intent is to inject the soft tissue surrounding the coccyx, might be appropriate. 88 Pain Management Coding Answers, 2016

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