Q: Injections, including nerve blocks and facet joints, require exhaustive documentation, especially if multiple levels are involved. What information should pain management coders ensure they have on hand when preparing claims? What information needs to be included in order for centers to receive full reimbursement and to avoid costly delays?
Richard Mann, CCA: Generally, in order for me to code pain management injections, I need to see in the operative report the route that the needle took and the final position of that needle, the spinal level(s) involved, whether fluoroscopic guidance was used, what medication was injected and the diagnoses that support the procedure.
Q: What are three of the most commonly used modifiers in pain management and what are some tips for using them correctly?
RM: The location modifiers — RT (right anatomically), LT (left anatomically) and 50 (bilateral anatomically, both right and left) — are the three modifiers that I use the most. Pain management injections often have timeframe restrictions regarding repeat injections; thus, identifying the correct anatomical locations is very important.
As an example: injections done at a particular spinal level(s) and side (say the left side) often cannot be repeated (by insurance carrier guidelines) until a period of time has passed, but injections can be done at the same spinal level(s) on the other side (the right side) during that timeframe, since that side had not been injected.
Q: Are there any recent changes to codes/procedures that pain management coders should be aware of and what can coders do to handle these changes?
RM: Facet joint injections (and related medial branch blocks) changed codes on Jan. 1, 2010. The guidelines for the old codes (64470-64476) allowed for any number of spinal levels to be coded, and fluoroscopic guidance (77003) was separately coded. The guidelines for the new codes (64490-64495) restrict the number of injections coded to three (unilateral or bilateral), and fluoroscopic guidance is included (not separately coded).
One thing to remember about these facet injection codes is that they are reported by facet joint, not necessarily by the number of injections. If the needle(s) is/are located within the facet joint, then code each injection. If the needles are located to target the individual medial nerves, then determine the facet joints by counting the number of nerves injected and subtract one. As an example: If the medial nerves at L2, L3, L4 and L5 are injected, then three facet joints (L2/3, L3/4 and L4/5) are coded.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.