Peggy Hapner, consulting services manager for MedLearn, a medical coding education and consulting firm, answers questions about recent changes in pain management coding and common challenges in coding pain management procedures.
Q: NCCI’s most recent edits (CCI 15.0) bundle payment for routine nerve blocks for post-operative pain administered before procedures with payment for the procedure. How will this effect coding?
Peggy Hapner: Coders are no longer able to code separately for nerve blocks (CPT 64400-64455) when billing Medicare for blocks that are routinely administered before certain procedures to control post operative pain. Under the NCCI edits, which became effective Jan. 1, providers must show medical necessity for these blocks if they bill them separately for these procedures. If physicians routinely provide these for a procedure, CMS says that they now must be bundled as part of the procedure. Most procedures where these blocks are regularly administered are included in bundling edit — one of the most common examples would be shoulder arthroscopy (CPT 29826). Nerve blocks can be billed separately (and indicated as a separate procedure with modifier -59), but the coder will need to have documentation that the block was not routine or was at a different level than the level that would have been administered routinely.
Q: What challenge does this create for coders and healthcare providers?
PH: Although CMS does not allow these blocks to be billed separately, the AMA’s coding guidelines says this is allowed, and some payors may continue to pay for them separately. As a result, healthcare providers must determine what their overall philosophy will be in regards to billing nerve blocks. Are you going to bill everyone the same or bill based on contracts? Are you going to follow NCCI edits for all payors? This is something that coders may have a lot of difficulty with if there isn’t an established philosophy. There is such conflicting information out there on when to use and when not to use modifier -59. The OIG is now watching for modifier -59 use with nerve blocks, so it’s something that coders need to be educated on and providers should audit regularly. Our general advice is that unless the documentation supports the block was used for a separate area or lesion, modifier usage is not appropriate.
Q: The AMA also recently introduced changes to its guidelines for coding joint injections? Could you explain the changes?
PH: Under current AMA guidance, paravertebral facet joint blocks (CPT 64400-64476) can be billed separately for each level. For example, a physician could inject L1, L2, L3, L4, L5 and be reimbursed for five levels. If these were bilateral, the use of modifier -50 would result in reimbursement for 10 levels of injection. However, starting Jan. 1, 2010, AMA is only allowing a single injection. Coders must include an add-on code for the second level as well as the third and any additional levels. For example, if a physician performs a paravertebral facet joint injection, the CPT would be 64493. The second level of this injection would be coded as 64494 and the third and any additional levels would be coded as 64495, which can only be used once per day. Now where you used to be reimbursed for five injections, you are reimbursed for a maximum of three per day per patient, unless performed bilaterally.
Q: In addition to preparing for these changes, what is one other challenge that providers should focus on regarding their pain management coding for 2010?
PH: Coders seem to always struggle with documentation. A common error is not understanding the difference between “L1, L2” and “L1-L2” in a physician’s notes. Commas and dashes completely change what is being billed. For example, a lumbar injection documented “L1, L2, L3” means that the physician is injecting into three different levels. An injection of the interspace between vertebra would be written as “L1-L2, L2-L3.” There is a lot of confusion among coders understanding where exactly the physician did the procedure. If there is any confusion at all, the best response is for the coder to go back to the physician who performed the surgery and ask for clarification. If a center bills for two levels when the physician only injected the interspace, the center is being over reimbursed, which creates risk. On the other hand, billing for an injection in the interspace when two levels were done leads to inadequate reimbursement. Coders need to really understand how various levels are documented and be willing to ask questions when they are unsure.
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Thank you to GENASCIS, who recently partnered with MedLearn to create CodeCypher, for arranging the interview with Ms. Hapner. Learn more about CodeCypher coding compliance technology.
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