Health Information Management

Code changes should help ease the pain when coding for facet joint injections

JustCoding News: Outpatient, January 27, 2010

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by Holly Cassano, CPC

The Office of Inspector General (OIG) released a report in September 2008 that may have sent chills down the proverbial spines of coders and physicians alike. The report titled Medicare Payments for Facet Joint Injections had two goals. One was to determine the extent to which Medicare Part B payments for facet joint injections meet Medicare program requirements. The second goal was to determine what policies and safeguards exist to ensure that Medicare Part B payments for facet joint injections meet Medicare program requirements.

Medicare Part B payments for facet joint injections increased from $141 million in 2003 to $307 million in 2006, according to the OIG report. During this same three-year period, the number of Medicare claims for facet joint injections increased by 76%.

React to report highlights

This OIG report should have sparked internal audits for private practices and facilities for payments of all claims for pain management facet joint injections for the prior year. Consider the following report statistics:

  • Sixty-three percent of facet joint injection services allowed by Medicare in 2006 did not meet Medicare program requirements. This resulted in approximately $96 million in improper payments. 
  • Medicare allowed an additional $33 million in improper payments for associated facility claims. 
  • Thirty-eight percent of facet joint injection services had a documentation error and 31% had a coding error.
  • For services that had a coding error, slightly more than 60% were overpaid because physicians incorrectly billed additional add-on codes to represent bilateral facet joint injections instead of using modifier -50. 
  • Eight percent of services had a medical necessity error. 
  • Fourteen percent of services had one or more overlapping errors. 
  • Facet joint injection services provided in an office were more likely to have an error than those provided in an ambulatory surgical center or hospital outpatient department.

Know the new codes for 2010

With these alarming OIG figures, it should come as no surprise that significant changes have taken effect in 2010, including the deletion of codes 64470–64476, which the AMA replaced with the following codes:

  • 64490: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or computed tomography[CT]), cervical or thoracic; single level
  • +64491: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level
  • +64492: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s)
  • 64493: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
  • +64494: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level
  • +64495: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s)

Use codes 64490–64492 to report injections at the cervical and thoracic levels, assigning code 64490 for a single or the first level injected and add-on code + 64491 for the second level. Report code +64492 for injections in the third level and any additional levels. You should not report code +64492 more than once per service date. Add-on codes are not subject to a multiple procedure reduction, therefore you should not append modifier -51 (Multiple procedure) to any of these codes.

Use codes 64493–64495, which are structured in the same manner as codes 64490–64492, for injections in the lumbar or sacral area. CPT® guidance clarifies that you should use code 64493 to report injections in the T12–L1 joint or nerves. Like its cervical/thoracic counterpart, you should not report code 64495 (third and any additional levels) more than once per service date.

For more guidance on applying these codes, access Transmittal 526 in the One-Time Notification Manual or MedLearn Matters article MM6518.

Understand which services are bundled

Prior to January 1, CPT guidelines stated that coders should separately report radiological imaging for needle placement, one unit per spinal region for the following codes:

  • 76942: Ultrasound guidance for needle placement
  • 77003: Fluoroscopic guidance for needle placement
  • 77012: CT guidance for needle placement

However in the CPT 2010 Professional Edition, the codes to report facet joint injections now include fluoroscopy or CT guidance for needle placement. This means that effective January 1, radiological imaging is bundled and no longer separately billable. Also, Medicare will not pay providers for more than three levels of facet joint injections. (Note: Some Medicare payers started to enforce limits on the number of levels to two or three after the OIG’s 2008 report.)

In addition, the new Category III codes to report facet injections include ultrasound guidance for needle placement. AMA creates Category III codes for “emerging technology, services and procedures,” according to the CPT 2010 Professional Edition. When Category III codes are available for what you are looking to report, you should use them instead of Category I unlisted codes.

Per the AMA, certain codes for paravertebral face joint injections took effect January 1 but won’t be published in the CPT Manual until 2011. The AMA stated:

Category III codes 0208T–0222T were accepted at the June 2009 CPT Editorial Panel meeting for the 2011 CPT production cycle. Therefore, these codes will not appear in the 2010 CPT codebook. However, due to the Category III code early release policy, these codes are effective on January 1, 2010, following the six month implementation period, which begins July 1, 2009.

Acknowledge the benefits of these changes

So what is the upshot of all of these changes? Separate codes for the different levels should hopefully put an end to duplicate denials and innocuous payer requirements to have modifiers appended to add-on codes.

Another boon is that these changes should foster a higher propensity for proper reporting and payment for bilateral procedures. These six new codes differentiated by cervical or thoracic, single level (code 64490), lumbar or sacral, single level (code 64493), as well as by second level (codes 64491 and 64494), and third and any additional level(s) (codes 64492 and 64495) all refer to unilateral injections. Therefore, coders should append modifier -50 when reporting bilateral procedures. Now that these six new codes help to eliminate confusion, when providers submit claims with modifier -50, payers should automatically know the modifier indicates a true bilateral procedure and pay the claims without prejudice.

In simpler terms, here are a few quick tips for applying these new codes:

  • When the physician uses imaging needle guidance, determine whether it is CT or fluoroscopy and refer to codes 64490–64495. If the physician uses imaging needle guidance and it is an ultrasound, refer to codes 0213T–0218T.
  • When the physician does not use imaging needle guidance, refer to codes 20550–20553.

I would strongly recommend having someone in your office maintain a spreadsheet to track CMS payment and denials for facet joint injection claims through the end of the second quarter of 2010 at minimum. Additionally, you should also keep a spreadsheet to track payments and denials from commercial payers when you apply these new codes and rules for reporting facet joint injections.

Contact your state’s CMS carrier to find out whether you can download any information from their medical policy section for these new codes. When assessing commercial payers, pull out your contracts and go online to see whether the payer has posted any new information on payments or medical policies. You’ll want to download this information and track it.

Editor’s note: Holly Cassano, CPC, is a medical coder and educator for the Emergency Department at the Cleveland Clinic Florida. E-mail her at hjcpmg@yahoo.com.



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