Pain Management Coding Handbook ™ ISBN: 978-1-63012-100-6 (online) 978-1-63012-099-3 (print)

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Accurately reporting pain management procedures and receiving all your practice’s deserved pay can seem like an insurmountable challenge. In addition to the day-to-day headaches, federal auditors are stepping up their review of Medicare claims for transforaminal epidural injections — which means you need to continue keeping a close check on your procedure coding for these services.

To keep up with the latest coding advice on the procedures that matter most to your practice, such as trigger point injections, nerve blocks, TENS, chemodenervation, and post-op pain management, you need a trusted resource that explains in plain English exactly what you need to know to file accurate claims. And with ICD-10-CM implementation coming, you’ll need a preview of how to document such commonly-reported diagnoses as neck pain and fibromyalgia so that code selection is clear.

The Coding Institute is pleased to bring you our Pain Management Coding Handbook 2015, your expert guide to successfully coding and billing your pain management services. Let our resource assist you in reducing your denials and building your practice’s bottom line.

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Pain Management Coding Handbook

Introduction to Pain Management Coding . . . . . . . . . . . . . . . . . . 1

Coding Nerve Blocks and InjectionsKeep Occipital Nerve Injection Headaches at Bay With These Strategies . . . . . . . . . . . . . . . . . . . 5

Reader QuestionsSubmit 64450 for Digital Block, If for Post-Op Relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8728.89 and 20550 Describe Iliotibial Band Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Submit 64999 With Documentation for Ganglion Impar Procedure . . . . . . . . . . . . . . . . . . . . . . . 9Choose 20552 or 20553 — Not 20605 — for Trigger Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Switch from 64483 to 0230T for Ultrasound Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Report Trigger Point Injections Per Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Watch Units and Bilateral with 64633, +64634 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Code With 64450 for Saphenous Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Distinguish Muscle, Nerve for Botulinum Toxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1264614 Applies to Multiple Gastrocnemius Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Check 20552 — and Maybe ABN — for Non-Guided SI Injection . . . . . . . . . . . . . . . . . . . . . . . . . 13J3490 Could Be Best for Lidocaine Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Check For Modifier 50 with 64614 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Learn Whether Payer Wants -50 or Double 64640 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Choose 20552 for Piriformis Injection, Not 64445 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Only Code Injection if No Manipulation Is Done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Pain Management Injection Doesn’t Always Include Other Service . . . . . . . . . . . . . . . . . . . . . . . 1664450 Applies to Post-Op Digital Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Coding Spinal Injections and ProceduresKnow the Differences Between AMA and Medicare Stances on Vertebroplasty . . . . . . . . . . . 18Know Your Anatomy to Better Understand Spinal Epidurals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Follow These 3 Steps to Capture Vertebroplasty Supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Avoid Denials by Correctly Counting Injections for Spinal Radiofrequency . . . . . . . . . . . . . . . 24Understand Facet Joint Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Payment Update: CMS Proposes Non-Coverage of Percutaneous Image-guided Lumbar Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Treatment News: Don’t Miss Medicare’s Final Decision on PILD Reimbursement - and When Patients Might Qualify for Coverage . . . . . . . . . . . . . . . . . . . . . . . . 29

Reader QuestionsAdministering Medial and Facet Injections During the Same Session . . . . . . . . . . . . . . . . . . . . 30Report Multi-Level Transforaminal Injections Separately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Verify Interlaminar Epidural Target Before Choosing the Best Guidance Code . . . . . . . . . . . . 31Report Each Level for Facet Joint Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Intervertebral Disc Biopsy Leads to 62267 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Levels and Guidance Are Keys to Facet Injection Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Include Add-On Codes for Multi-Level Kyphoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Use Add-Ons When Vertebroplasty Crosses Spinal Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Ensure That Documentation Supports Bilateral Injection Coding . . . . . . . . . . . . . . . . . . . . . . . . 35Stick to 1 Line Item of 64421 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Yes, You Can Include Fluoro for Interlaminar Epidural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

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Lumbar Sympathetic Chain RF Leads to 64999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Is 64483 Not Allowed? Then Also Skip +64484 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Don’t Miss a Diagnosis of Polyradiculopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Understand Levels and Sites for 64633-64636 Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Turn To Level, Not Session for 72285 and 72295 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39O-A and A-O Joints Are Same as Paravertebral Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Transforaminal Overrides Interlaminar ESI Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4199144 Can Be OK With Epidural Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Multi-Level Transforaminal Injections Get Separate Line Units . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Coding Updates: CPT®, CCI, and ICD-10CPT® 2014: Catch the Chemodenervation Corrections to CPT® Coding Descriptors . . . . . . . . 43CCI 20.0: Report Chemodenervation Ahead of 1000s of Other Procedures When Following CCI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45AMA Symposium: Get the Lowdown on New Guidelines for Chemodenervation . . . . . . . . . . 47ICD-10: Crack This Chronic Neck Pain Code Equivalent in ICD-10 . . . . . . . . . . . . . . . . . . . . . . . . . 49ICD-10: Lumbar Spinal Stenosis Codes 724.02 and 724.03 Will Funnel to Same ICD-10 Choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ICD-10: Underlying Condition Will Be Key to Choosing Pathological Fracture Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Reader QuestionsCheck for Current Codes, But NCS/Nerve Block Edit Still Applies . . . . . . . . . . . . . . . . . . . . . . . . 52ICD-10 is More Specific for Fibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Coding Other Pain Management SituationsFollow 6 Tips to Unlisted Procedure Claims Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Check Your Claim Before Reporting Infrared Therapy Treatments . . . . . . . . . . . . . . . . . . . . . . . . 56Don’t Get Tense Over Coding Dupuytren’s Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Dupuytren’s Contracture Defined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Your 3-Step Guide to Submitting Successful TENS Claims, Despite CMS Snub . . . . . . . . . . . . . 59Treatment Focus: Here’s How TENS Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Follow 4 Strategies to Post-op Pain Management Coding Success . . . . . . . . . . . . . . . . . . . . . . . . 62

Reader QuestionsUnderstand Full Meaning of Modifier 53 to Choose Appropriately . . . . . . . . . . . . . . . . . . . . . . 64Verify Payer Preference, Type of Test Kit for 80101 Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Don’t Jump to 346.x for Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Submitting Lab Tests With MILD Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66Pain Pump Removal Leads to 62365 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Get More Details for Post Meningitis Headache Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Save 01996 for Daily Epidural Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Check Global Period Before Coding Pain Pump Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

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Introduction to Pain Management Coding

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Pain Management Coding Handbook

Intr

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gPain management coding encompasses both general services and more intricate procedures performed by a pain management specialist. Here, you’ll find explana-tions of and information about coding for some of the more common pain manage-ment procedures any provider might offer.

Code Pain Management Separately The fees for anesthesia services include the pre-anesthesia work-up, anesthesia administration, and supervision until another provider assumes responsibility for the patient (such as when the PACU staff takes over). If your physician provides other services related to pain management that are represented by codes outside CPT®’s anesthesia chapter (codes 00100-01999), you might be able to code sepa-rately for them if you have adequate documentation, especially if the physician only performs the pain management service during that patient encounter.

Distinguish Between Chronic and Acute Pain, Diagnostic and Therapeutic When coding for pain management services, it’s important to know the difference between acute and chronic pain.

Acute pain begins suddenly and can range from mild to severe. The pain can last for a few minutes up to months, although it typically doesn’t last more than six months. Surgery, broken bones, dental work, or other short-lived conditions can cause acute pain. The pain is resolved when its source is identified and treated.

Chronic pain may be caused by unrelieved acute pain and can persist even after the underlying cause is resolved. Common effects of chronic pain can include tense muscles, limited mobility, lack of energy, depression, anxiety, and more. Once a patient visits a pain management specialist for help, his or her condition usually has been diagnosed as chronic pain that might need long term treatment.

Terminology tip: Postoperative pain and post-thoracotomy pain not specified as acute or chronic defaults to the code for the acute type. If postoperative pain is associated with a specific postoperative complication, assign the appropriate code from diagnosis 338.x (Pain). List the postoperative pain code as the first (or primary) diagnosis when the patient is admitted for postoperative pain control or pain management. List the postoperative pain code as the secondary diagnosis when the patient develops an unusual amount of postoperative pain after outpa-tient surgery.

Physician notes should document whether the patient received a diagnostic or therapeutic injection during the encounter. Simply put, physicians use diagnostic injections (or blocks) to help determine the source(s) of the patient’s pain. The block

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typically contains an anesthetic to help relieve pain for a known length of time. Therapeutic nerve blocks or injections contain local anesthetic to control acute pain. The provider admin-isters therapeutic blocks once the source and cause of the patient’s pain are confirmed.

Many CPT® code descriptors mention “diagnostic and therapeutic” or “diagnostic or thera-peutic.” That means you could possibly report the same code for both the diagnostic and therapeutic injections, based on the type of block and the administration route.

Example: A provider might inject an anesthetic and a steroid into a facet joint or a peripheral nerve to determine whether that is the source of the patient’s pain. In that situation, a nerve block might be both diagnostic and therapeutic. Payers want to know whether the block is diagnostic or therapeutic. Specifying such can be a criterion of coverage. Educate your physicians on the importance of documenting whether the patient receives a diagnostic or therapeutic block.

Look for Separate Service Regarding Post-Op Management Postoperative pain management is considered the surgeon’s responsibility. Sometimes, however, the surgeon will request that a specialist provide pain management services for a patient following surgery. The block administration route and the specialist’s documentation will dictate whether you can code separately for the service.

Crucial: Documentation must support that the postoperative block was performed separately from the anesthesia given during surgery. If the specialist administers a narcotic or other analgesic for post-op relief through the same catheter used for anesthetic during surgery, you cannot report the post-op care separately. If the specialist documents separate administration and the reason for it, however, you can submit the pain management injection code (such as 62310 or 62311) in addition to the surgical anesthesia. Append modifier 59 (Distinct proce-dural service) to the post-op injection code to indicate the injection was a separate service. The specialist’s procedure notes should document the service in the medical record.

Follow up: If you’re able to code for the catheter placement, you can also report additional days if your physician provides follow-up care during the postoperative period. The correct follow-up code will depend on the type of catheter and administration route. If the anesthe-siologist uses an epidural or subarachnoid catheter, you could submit 01996 (Daily hospital management of epidural or subarachnoid continuous drug administration) for each follow-up day. If the pain management specialist used another type of catheter (such as a femoral nerve continuous catheter you would report with 64448 [Injection, anesthetic agent; femoral nerve, continuous infusion by catheter {including catheter placement}]), you would submit the appropriate subsequent hospital care code (99231-99233) for each day of follow-up care.

Remember Trigger Point Injections Focus on Muscle NumberPhysicians use trigger point injections (TPI) to treat painful knots of muscle that form when muscles do not relax. Trigger points can irritate the nerves around them and cause referred pain (pain that is felt in another part of the body).

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During a TPI procedure, the provider inserts a small needle into the patient’s trigger point and injects a local anesthetic. The injection makes the trigger point inactive and relieves the patient’s pain. A brief course of TPI treatments often will lead to sustained relief.

When coding for TPIs, you’ll need to know how many muscles your physician injected. The code choices are:

� 20552 — Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) � 20553 — … single or multiple trigger point(s), 3 or more muscle(s).

Tips: Report one TPI code per session based on the number of muscles injected, not the number of injections given. You also should never submit a claim with both 20552 and 20553 for the same patient encounter. Report fluoroscopic guidance with 77002 (Fluoroscopic guid-ance for needle placement [e.g., biopsy, aspiration, injection, localization device]).

Count Spaces, Not Vertebrae, for Transforaminal Epidurals The Office of Inspector General (OIG) Work Plan for several years included a closer look at Medicare payments for transforaminal epidural injections — which means you need to continue keeping a close check on your procedure coding. Ensure that your pain manage-ment specialist documents each procedure thoroughly by keeping several keys in mind.

Procedure: Physicians often administer transforaminal epidurals laterally through the selected neuroforamen under fluoroscopy. Once there, the physician performs an injection at the nerve root area to help relieve the patient’s pain. The medication goes into the anterior epidural space, “bathing” a specific spinal nerve as it exits the spinal cord.

CPT® includes four codes to represent transforaminal epidural injections, which you choose between based on the injection site and number of injections:

� 64479 — Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level

� +64480 — … cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

� 64483 — … lumbar or sacral, single level � +64484 — … lumbar or sacral, each additional level (List separately in addition to code

for primary procedure).

Detail: Although you report the same codes, a transforaminal injection is different from a selective nerve root block (SNRB). With SNRB, your provider injects right beside the nerve root where the nerve exits the foramen. The injection occurs outside the spine, which differs from a transforaminal. Coders sometimes interchange the terms, but knowing the difference in technique will help you better understand your physician’s documentation.

Spaces count: Although the transforaminal injection descriptors specify spinal levels, your physician actually targets the space between vertebrae — the interspace. This difference

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in code terminology and the procedure can confuse coders, so remember you’re counting interspaces, not vertebral bodies.

Example: When the provider inserts the needle through the foramen into the inter-space between discs (for example, at L4-L5), that is a spinal level you code with 64483. If your provider inserts another needle into the next interspace (for example, at L5-S1), consider that a second spinal level and code report +64484 along with 64483.

If your provider injects both sides of the same level, report a bilateral injection, not separate levels. Check your payer’s guidelines for bilateral reporting so you’ll submit a correct claim. When reporting a unilateral block with 64479-64484, include modifier LT (Left side) or RT (Right side) as appropriate so the payer fully understands the procedure.

Most providers use fluoroscopic guidance when administering transforaminal epidural injec-tions. You’ll need documentation of fluoroscopic guidance in the medical record as well as a hard copy of the film. The correct code for fluoroscopic guidance in conjunction with trans-foraminal epidurals is 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transfo-raminal epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) in addition to the procedure code.

Check the Latest Fluoroscopy Rules Physicians often use fluoroscopy to help guide the approach for diagnostic or therapeutic injections. This process of injecting a small amount of special dye allows the provider to see nerves, joints, or other anatomic structures more clearly. Using fluoroscopy — or fluoroscopic guidance — increases the physician’s accuracy when administering the injection.

CPT® includes several codes for fluoroscopic guidance during needle placement or diag-nostic or therapeutic injections. Check code descriptors and your local guidelines carefully, however, before automatically reporting fluoroscopy with an injection procedure.

Example: CPT® 2010 introduced codes 64490-64495 for paravertebral facet joint injections. Each code descriptor includes the verbiage “with image guidance,” which means you cannot report 64490-64495 with CT or fluoroscopic image guidance. v

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Get More Details for Post Meningitis Headache CodeQuestion: A patient developed pneumocephalus meningitis after an attempt to open a blocked tear duct. I’m having trouble finding a proper ICD-9 code for post meningitis persistent headache. The best I’ve found so far is 339.2x. Is there a better choice?

Montana Subscriber

Answer: Since ICD-9’s alphabetic index doesn’t list a code for post-pneumocephalus or post-menin-gitis persistent headache, your first step should be querying the provider for an accurate diagnosis. Potential codes could include:

� 339.2x – Post-traumatic headache � 339.42 – New daily persistent headache � 339.44 – Other complicated headache syndrome � 339.89 – Other headache syndrome.

Remember: Just because the term “persistent” is used in the new daily persistent headache diagnosis does not mean that this would be the appropriate diagnosis to report. This specific condition has more requirements than just being consistent that are not specified in the infor-mation provided in the question – “post pneumocephalus meningitis persistent headache.” v

Save 01996 for Daily Epidural ManagementQuestion: Other coders in our department are using 01996 only for epidurals. If the anesthesiologist places some other kind of block, they’re using a two-unit consult code for the daily manage-ment. Is that right, or should they be coding 01996 for situations other than epidurals?

Connecticut Subscriber

Answer: Your coworkers are correct. Code 01996 (Daily hospital management of epidural or subarach-noid continuous drug administration) should be used for daily management of a continuous epidural or subarachnoid drug administration after the anesthesiologist places an epidural or subarachnoid catheter for postoperative pain management.

The descriptors for several common blocks used for post-op management no longer include daily management:

� 64416 – Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement)

� 64446 – … sciatic nerve, continuous infusion by catheter (including catheter place-ment)

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� 64448 – … femoral nerve, continuous infusion by catheter (including catheter place-ment)

� 64449 – … lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement).

Coding notes with these procedures specify that you should not report these codes in conjunction with 01996. Instead, when your provider uses one of these types of blocks for post-op pain management, you should report the block code based on the anatomic site and the appropriate E/M code. v

Check Global Period Before Coding Pain Pump RemovalQuestion: Our physician removed an implanted pain pump and catheter from a patient whose pain pump was implanted 9 days ago. When the abdominal wound was opened, some fluid was found in the cavity which was sent for culture. How should we code the pain pump removal? Can we also bill for the wound culture? Can we bill for the swab obtained from the wound fluid and sending it for laboratory culture?

Florida Subscriber

Answer: You may report code 62365 (Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion) for removal of the pump and 62355 (Removal of previously implanted intrathecal or epidural catheter) with modifier 51 (Multiple procedures) for removal of the catheter.

Note: The procedure carries a 10-day global period, and the pump removal took place before that global period had expired. Therefore, also append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period …) since the procedure is being performed within the global period and wasn’t anticipated.

Pain pumps generally are implanted for long-term pain management and often are not removed very frequently. In a rare instance of the patient ceasing to respond to the pain pump, the physician may decide to remove the pain pump and the catheter. However, the catheter or the pump itself may develop a problem and need to be replaced, such as in the setting of postoperative infection.

There is no separate charge for swabbing the wound and sending the sample to the labora-tory for culture. You do not report any separate code for this service. v