CONFUSING Some pain management procedures are billable with other procedures and some are not.

Just as with epidural steroid injections, one false move when you're coding these pain procedures can spell big trouble. But as you'll see, there are many cracks for reimbursement to fall through when you're coding and billing many commonly performed pain procedures.

If an insurer will only pay for a patient to have an injection once every 90 days and you treat him at 60 days, your claim will be denied. If your doctor uses a different code in his claim than your coder, your claim will be denied. If you don't list a covered diagnosis as your first diagnosis on your claim form, Medicare won't pay you. This list goes on. Here's a review of pain management injections for chronic pain that are particularly confusing to code.

Epidural steroid injections
The regular epidural steroid injection (ESI) procedures (CPT Codes 62310-62319) are also referred to as translaminar injections (don't confuse these procedures with transforaminal ESI procedures, which we'll cover next). These injections are done midline. Because you place the injection in the middle of the back, you can only bill them once per case. Don't use LT or RT modifiers.

• 62310. cervical or thoracic epidural injections (not via indwelling catheter) are for patients with pain in the arms, neck, chest or high back area.
• 62311. lumbar or caudal epidural injections are for patients with pain in the legs and/or lower back/buttock(s) area.
• 62318. ESI continuous infusion or bolus, including catheter placement, by continuous infusion or intermittent bolus.
• 62319. ESI continuous infusion or bolus (lumbar or sacral [caudal]).

For codes 62310 or 62311, ESI procedures can be done using a needle or a catheter. However, don't bill codes 62318 or 62319 unless the patient leaves with the catheter still in place.

Imaging is not separately billable on most pain procedures, which now include the fluoroscopy, so don't unbundle them. Another rule: If you previously billed for fluoroscopic guidance, most of the time you can no longer use CPT code 77003-TC to bill the fluoroscopy separately.

Transforaminal epidural injections
Transforaminal ESIs, also called selective nerve root blocks, are more difficult to perform, due to the close proximity of the nerve root to the vertebral artery and spinal cord. They're performed under fluoroscopy for precise anatomic localization, to avoid injury to the vertebral artery. The contrast will be in either the foramen into the epidural space, or it will be in a fascial plane or epidural vein.

These codes are unilateral procedure codes. The procedure is performed bilaterally on either side of the midline, so you'd bill in a bilateral manner by appending either the -RT/-LT or the -50 modifier.

Imaging (fluoroscopy, computed tomography) is considered part of the procedure here as well, so you can't bill separately for fluoroscopy with code 77003-TC.

Use different codes for each additional level: Use code 64479 for a cervical or thoracic single-level injection and 64480 as an add-on code for each additional level. Medicare won't reimburse for add-on codes, but many commercial payers will.

What if you perform both a translaminar and a transforaminal injection on the same patient? These codes are not billable together when they're performed at the same spinal area because they are unbundled in the Medicare CCI edits. They'd have to be done at different spinal levels to be payable. For example, if you do the epidural (62311) at level L5 and the transforaminal epidural (64483) at area L4-5, the procedures are unbundled and not both billable. Only code 62311 would be billable in that case.

However, if the physician does an ESI (62311) at level L5 and a transforaminal ESI (64483) at area L3-4, you can bill both codes, so long as you put the -59 modifier on the 64483 code and bill it as the second code following the 62311 ESI code on the claim form. The same bundling rule applies to CPT 64483 and +64484 (lumbar and sacral injections). You won't be paid beyond the first level injection by Medicare.

Transforaminal ESI injections with ultrasound guidance
Medicare covers Category III CPT procedures for a TESI with ultrasound.

• 0228T. Single level cervical or thoracic injections.
• 0229T. Each additional level cervical or thoracic injection (list separately in addition to the code for primary procedure, which is an add-on code for an injection at a level subsequent to the first level performed).
• 0230T. Single level lumbar or sacral injections.
• 0231T. Each additional level lumbar or sacral injection (list separately in addition to the code for primary procedure, which is an add-on code for an injection at a level subsequent to the first level performed).

Facet joint nerve injections
Facet injections, also referred to as medial branch blocks, involve the physician placing the spinal needle at the medial branch nerve of the facet joint (the cervical or thoracic areas), which is smaller than the lumbar area, making the cervical and thoracic procedure a higher risk than those performed in the lumbar area. Codes 64490-64495 are unilateral procedure codes; if the procedure is performed bilaterally, you need to bill in a bilateral manner by appending either the -RT/-LT or the -50 modifier (usually not for use on Medicare claims).

The codes for these procedures have a different code for each level billed. The last code allowable for each spinal area (for example, cervical or lumbar) is for the 3rd level and the code states that it "cannot be billed more than once per day," which in CPT rules means you can only bill a maximum of 3 levels. So, if the physician performs facet injections at a 4th level or beyond, there is no code for those levels and they are not billable. While the direction in the CPT book is to use the -50 modifier if these procedures are performed bilaterally, Medicare doesn't let ambulatory surgical centers use the -50 modifier to bill bilateral procedures in most states. Instead, use the RT/LT modifiers for bilateral procedures when billing these codes to Medicare. OSM