A.
Use of
Fluoroscopy. , Fluoroscopic guidance, CPT codes 77002 and 77003, may be
billed once per date of service. Use CPT code 77002, fluoroscopic guidance for
needle placement with CPT code 64510, injection anesthetic agent; stellate
ganglion (cervical sympathetic) , or CPT code 64520, injection anesthetic
agent; lumbar or thoracic (paravertebral sympathetic).
Use CPT code 77003, for fluoroscopic guidance and
localization of needle or catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (e.g., cervical epidural or sacroiliac joint),
and including facet nerve neurolytic agent destruction.
All procedures performed fluoroscopically MUST have stored
hard copy or digital images showing final needle placement in at least two (2)
views (typically posterior/anterior and lateral or oblique) demonstrating final
needle placement and depth AND disbursement of contrast (when not
contraindicated). These images must be available upon request (with appropriate
HIPAA compliance) by payers, or reimbursement may be denied.
Fluoroscopy will be reimbursed for the following codes:
27096, 62321, 62323, 64479-64484, 64490-64495, 64600-64681, 64633-64636.
B.
Reimbursement for
Injection/Destruction Procedures
1.
Facet injections and medial branch blocks are reimbursed at a maximum of three
(3) total anatomic joint levels. Additional level or bilateral modifiers may be
used to allow up to a maximum of two (2) additional service levels for facet or
medial branch blocks in the cervical/thoracic (64491 and 64492) or lumbar
(64494 and 64495) for a maximum of three (3) procedure levels reimbursed per
treatment session or day. These procedures are unilateral by definition.
Bilateral modifiers may be used when nerves are treated bilaterally.
Reimbursement of the bilateral modifier is twenty five percent (25%) of the
base amount for the second or contralateral side for procedures listed in the
Pain Management section.
2. Nerve
destructive procedures are reimbursed for a maximum of two (2) anatomical
levels.
3. Reimbursement for
injection/destruction procedure codes is made on the basis of joint levels, not
nerves treated (e.g., destruction by neurolytic agent of the L4-L5 facets
counts as one (1) level/nerve and should be billed as 64635 (first
level/nerve)). There are two nerves supplying each joint but reimbursement is
based upon joint(s) treated, not the nerves treated. This applies to CPT codes
64635, 64636 (lumbar), and 64633, 64634 (cervical/thoracic). These procedures
are unilateral by definition. Bilateral modifiers may be used when nerves are
treated bilaterally. Reimbursement is twenty five percent (25%) of the base
amount for the second or contralateral side when the bilateral modifier is used
for procedures listed in the Pain Management section.
4. A maximum of two (2) levels of
transforaminal epidural steroid injections or one level bilaterally are
reimbursable for a given date of service. This applies to codes 64479, 64480,
64483, and 64484.
5. A maximum of
one (1) interlaminar epidural steroid injection is reimbursable for a given
date of service. This applies to codes 62320 and 62322.
6. If a patient with bilateral pain receives
only unilateral treatment on a given date of service, any similar procedures
(same CPT codes) performed on the contralateral side within ninety (90) days of
the initial procedure will be subject to reimbursement reductions related to
modifiers for bilateral treatment on the same date of service. For example, if
a person undergoes a right sided medial branch block(s) or neurotomy(ies) on a
given date of service, any similar procedure(s) on the left side will be
subject to the reductions in reimbursement related to use of the bilateral
modifier if this treatment is provided within ninety (90) days of the date of
service of the right sided procedures. This rule applies to professional and
facility reimbursement.
C.
Multiple Procedure
Reimbursement. Only one (1) type of pain management procedure is
reimbursable on a given date of service, unless otherwise approved by the
payer. This rule does not include multiple level injections or bilateral
procedures of the same type, with appropriate modifiers.
"Type" is defined as any procedure code involving an
anatomically different structure (e.g., spinal nerve, facet joint, sacroiliac
joint, trigger point, etc.). Joints and nerves in different anatomical regions
(cervical/thoracic, lumbar/sacral) are considered to be different "types" and
is limited to one (1) procedure per given day. Additional level or bilateral
injections of a single procedure in the same area are not considered different
"types," and for the purpose of this rule, are considered to be the same
"type." However, the multiple level restrictions, as detailed herein, still
apply. Diagnostic injections of more than one type in the same anatomic area on
the same date of service are prohibited, and will not be reimbursed without
prior authorization. Reimbursement of the multiple procedure modifier (51) is
twenty-five percent (25%) of the base amount for the second or additional
procedure for procedures listed in the Pain Management
section.
D. Repeat epidural
injections would typically occur two to four (2-4) weeks after the initial
treatment, contingent upon some degree of continuing radiating pain. Repeat
injections performed within ten (10) days of the previous epidural injection
will not be reimbursed.
E.
Sacroiliac arthrography (CPT code 27096) assumes the use of a fluoroscope and
is considered an integral part of the arthrography procedures(s). Therefore, no
additional fee for the fluoroscopy (CPT code 77002) will be reimbursed. This
code may only be used twice per twelve (12) month period.
F. Epidurography (CPT code 72275) is not
reimbursable under this Fee Schedule.
G. CPT code 62324 includes needle placement,
catheter infusion, and subsequent injections. Code 62324 should be used for
multiple solutions injected by way of the same catheter, or multiple bolus
injections during the initial procedure. The epidural needle or catheter
placement is inherent to the procedure, and, therefore, no additional charge
for needle or catheter placement is allowed.
H. Pain management procedures or services
which are included in this section of the Fee Schedule must be performed by a
licensed physician holding either an M.D. or D.O. degree. Pain management
procedures performed by any other person, such as a Certified Registered Nurse
Anesthetist (CRNA), are not eligible for reimbursement.
I. The following procedures must be performed
fluoroscopically in order to qualify for reimbursement:
1. Facet injections (64490-64495)
2. Sacroiliac (SI) injections
(27096).
3. Transforaminal epidural
steroid injections (64479, 64480, 64483, 64484).
4. Cervical translaminar/interlaminar
epidural injections 62321
5.
Cervical/thoracic discography (CPT codes 62291 injection cervical/thoracic
disc) and radiology supervision and interpretation (CPT code 72285) will not be
reimbursed.
J. Any
analgesia/sedation used in the performance of the procedures in this section is
considered integral to the procedure, and will not be separately reimbursed.
This rule applies whether or not the person administering the
analgesia/sedation is the physician who is performing the pain management
injection. Administration of analgesia/sedation by a different person from the
physician performing the injection, including an RN, PA, CRNA, or MD/DO, does
not allow for separate billing of analgesia/sedation. If a patient is unable to
cooperate during routine needle placement, despite judicious use of sedation
for anxiety, elective IPM interventional pain management) procedures should be
terminated due to patient safety concerns. Sedating or anesthetizing a patient
into a plane of deep sedation or anesthesia, rendering them unconversant or
unable to experience or communicate unusual or excessive pain puts the patient
at increased risk for elective IPM procedures.
K. Detailed anatomical descriptions of the
procedures performed must accompany the bill for service in order to qualify
for reimbursement. These descriptions must include landmarks used in
determining needle positioning, needles used (size, length), and the type and
quantity of each drug injected. Unless there is a contraindication to contrast
media (e.g., documented allergy) it is expected that the quantity of contrast
injection AND a written description of the contrast spread pattern be included
in the procedure report. Generic descriptions such as "the procedure was
performed in the usual fashion," "the needle was placed on (next to, by, etc.)
the nerve/joint/target," "the needle was placed in the correct anatomical
location," or similar wording, which was templated or otherwise lacking an
actual detailed anatomical description of needle placement or contrast pattern
(where appropriate), is inadequate and cause for denial of payment. Templates
for standard needle placement are acceptable, but any deviation from the usual
technique must be explained in the procedure note. Contrast injections patterns
should not be templated. Tolerance to the procedure, and side effects or lack
thereof should be included in this documentation.
L.
Radiographic Codes in Pain
Management.
1. Fluoroscopic imaging is
reported with codes 77002 and 77003.
2. Codes 72020-72220 which apply to
radiographic examination of the spine are not reimbursed when performed with
the pain management procedures in this section or with fluoroscopy services. If
fluoroscopy codes 77002 and 77003 are used, appropriate images must be stored
to receive reimbursement for the fluoroscopy code AND the procedure code for
which fluoroscopy was reportedly used. This includes pre and post contrast
images (unless contraindicated by contrast allergy) and at least two (2) views,
posteroanterior (PA) and a depth view (oblique or lateral).
3. Fluoroscopic codes will be reimbursed for
the following codes: 27096, 62321, 62323, 64479-64484, 64490-64495,
64600-64681, 64633-64636
M. When a joint injection is performed at the
end of a surgical procedure for pain control, reimbursement is allowed
according to the Multiple Procedure rule. This rule applies to professional and
facility reimbursement.
N.
Reimbursement of the bilateral modifier is twenty-five percent (25%) of the
base amount for the second or contralateral side for procedures listed in the
Pain Management section.
