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All bundled up: Epidural injections and fluoroscopy

In the 2015 Physician Fee Schedule Final Rule of the Federal Register, the Centers for Medicare and Medicaid Services (CMS) bundled fluoroscopic guidance into epidural injections and stated that fluoro was no longer separately reportable.

The National Correct Coding Initiative (NCCI) Edits, which is where CMS defines what procedures are bundled, did not reflect this change on January 1, 2015. The NCCI Edits are updated quarterly and in the most recent release dated April 2015, fluoroscopic guidance was bundled into the epidural injection codes.

What this means is that Medicare and Medicaid (and any private payers who follow NCCI edits [i.e., United Healthcare, etc.]) will no longer reimburse separately for fluoroscopy when done with an epidural injection. Of note, this bundling issue does not change the First Coast LCD (Local Coverage Determination) Policy which mandates epidural injections must be done under fluoroscopic guidance in order to be considered medically necessary. First Coast is the Medicare payer for Florida.

It should also be noted that private payers that do not technically follow NCCI edits may still have their own set of internal edits which tend to mirror the CMS NCCI edits in many respects. In fact, private payer denials have already been noticed.

As imaging guidance is increasingly determined to be an inherent component of pain blocks, the fewer opportunities there will be to bill separately for this service, whether it is fluoroscopic or ultrasound guidance. With NCCI edits, anesthesiologists may find an occasional payer who will reimburse them separately for services CMS considers to be bundled. The NCCI edits are developed and maintained by CMS and while some private payers adopt this policy, others may have similar policies that may or may not include this edit.

There is also a trend to bundle imaging guidance into new or revised CPT codes, such as the new TAP block codes released this year. Since the ultrasound guidance is included at the CPT description level the guidance would be considered "bundled" for all payers.

Pamela Linton, CPC, CANPC is an anesthesiology and pain management coding specialist with Zotec Partners.

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