2017 Pain Management Coding Amy Turner, RN, BSN, MMHC, CPC

Epidural Steroid Injections Indications for ESI Radicular Pain (pain down leg or arm) Post Laminectomy Syndrome Low Back Pain due to central or lateral disc herniation, degenerative disc disease, facet hypertrophy and foraminal or central spinal canal stenosis Image Requirements Plain films to rule out fracture or malignancies MRI or CT may be appropriate prior to ESI Epidural Steroid Injections

Image: MMG, 2005 eorthopod.com Mayfield Clinic

Lumbar Interlaminar Epidural Steroid Injection Current CPT 62311 Contrast included Must be performed with imaging guidance. Films with needle placement and injectate flow retained No Bilateral Fluoroscopy 77003 if allowable by payer Lumbar Interlaminar Epidural Steroid Injection Image: MMG, 2005 eorthopod.com

Proposed replacements Current Proposed replacements 62311-Injection(s) of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Work RVU- 1.54 $228.94 623X7- Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Work RVU- 1.55 $153.37 623X8- Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT) Work RVU- 1.80 $246.67

Lumbar Transforaminal ESI CPT 64483- Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral; single level CPT 64484- lumbar or sacral, each additional level (list separately in addition to code for primary procedure) Bilateral allowed for both primary and additional level 50 modifier No Global period 64483 2016 $225.36 2017 $232.69 3.3% increase 64484 2016 $90.29 2017 $92.93 2.9% increase Lumbar Transforaminal ESI

Right L2 and L3 Transforaminal ESI 64483 64484 Bilateral L3 Transforaminal ESI 64483 50 modifier This is not a 2 level injection Right L3 Transforaminal and Left L3 Transforaminal ESI 64483 50 modifier This is not a 2 level injection Image- 08/30/16 MMG, 2005 eorthopod.com

Cervical Interlaminar Epidural Steroid Injection Current CPT 62310 No specific LCD for Palmetto. No Bilateral Contrast included Fluoroscopy- 77003 if allowable by payer Cervical Interlaminar Epidural Steroid Injection

Proposed replacements Current Proposed replacements 62310- Injection(s), of diagnostic or therapeutic substances(s) (including anesthetic, antispasmodic, opioid, steroid, other solution) not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic Work RVU 1.91 $247.93 623x5- Injection(s), of diagnostic or therapeutic substance(s) (e.g. anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Work RVU 1.80 $164.70 623x6- With imaging guidance (i.e. fluoroscopy or CT) Work RVU 1.95 $251.58

Cervical Transforaminal Epidural Steroid Injection CPT 64479- Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic; single level CPT 64480- cervical or thoracic; each additional level (list separately in addition to code for primary procedure) Bilateral allowed for both primary and additional level 50 modifier No Global period 64479 2016 $242.20 2017 $250.83 +3.6% 64480 2016 $116.08 2017 $120.50 +3.8% Cervical Transforaminal Epidural Steroid Injection

Cervical Transforaminal Epidural Steroid Injection Image- 08/30/16 MMG, 2005 eorthopod.com

Interlaminar Epidural Steroid Injection at C7-T1 62310 Interlaminar Epidural Steroid Injection at T 12-L1 62310 Transforaminal ESI C 4 and C 5 on right 64479 64480 Transforaminal ESI C 5 Bilaterally 64479 50 modifier

Medical Necessity Per Palmetto LCD Lumbar ESI L35148 (sample only) B02.23- Post herpetic polyneuropathy M48.06- Spinal stenosis, lumbar region M51.15-17- Intervertebral disc disorders with radiculopathy (thoracolumbar M51.15, lumbar M51.16 or lumbosacral M51.17) M54.15-18- Radiculopathy, (thoracolumbar M54.15, lumbar M54.16, lumbosacral M54.17, sacral M54.18) M96.1- Post Laminectomy Syndrome, NOS Medical Necessity

M50.02 Cervical disc disorder with myelopathy, mid-cervical region Add- M50.020- Cervical disc disorder with Myelopathy, mid- cervical region, unspecified level Add- M50.021- Cervical disc disorder at C4-C5 level with myelopathy Add- M50.022- Cervical disc disorder at C5-C6 level with myelopathy Add- M50.023- Cervical disc disorder at C6-C7 level with myelopathy M50.12- Cervical disc disorder with radiculopathy, mid cervical region Add- M50.121- Cervical disc disorder at C 4-C5 with radiculopathy Add- M50.122- Cervical disc disorder at C5-C6 with radiculopathy Add- M50.123- Cervical disc disorder at C6-C7 with radiculopathy ICD 10 changes for 2017

M50.22 Other cervical disc displacement, mid cervical region Add- M50.221- Other cervical disc displacement at C4-C5 level Add- M50.222- Other cervical disc displacement at C5-C6 level Add- M50.223- Other cervical disc displacement at C6-C7 level M50.32 Other cervical disc degeneration, mid cervical region Add- M50.321- Other cervical disc degeneration at C4-C5 level Add- M50.322- Other cervical disc degeneration at C5-C6 level Add- M50.323- Other cervical disc degeneration at C6-C7 level M50.82 Other cervical disc disorders, mid cervical region Add- M50.821- Other cervical disc disorders at C4-C5 level Add- M50.822- Other cervical disc disorders at C5-C6 level Add- M50.823- Other cervical disc disorders at C6-C7 level ICD 10 changes for 2017 (cont)

M50.92 Cervical disc disorder, unspecified Add- M50.921 Unspecified cervical disc disorder at C4-C5 level Add- M50.922 Unspecified cervical disc disorder at C5-C6 level Add- M50.923 Unspecified cervical disc disorder at C6-C7 level Add- N50.81 Testicular Pain Add N50.811 Right testicular pain Add N50.812 Left testicular pain Add N50.819 testicular pain, unspecified Add- N50.82 Scrotal Pain F11.10 Opioid abuse, uncomplicated Add description- Opioid use disorder, mild F11.20 Opioid dependence, uncomplicated Add description- Opioid use disorder, moderate Add description- Opioid use disorder, severe ICD 10 changes for 2017 (cont)

20600- Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, finger, toes; without ultrasound guidance 20604- With ultrasound guidance with permanent recording and reporting CANNOT bill US- 76942. If using fluoro- use 77002 fluoroscopic guidance for needle placement 20604 includes ultrasound guidance. DO NOT use for fluoro guidance Joint Injections Image- 08/30/16 MMG, 2004 eorthopod.com

Intermediate Joint Injections 20605- Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance. 20606- with ultrasound guidance, with permanent recording and reporting 20605- CANNOT be billed with 76942. If fluoroscopy used- 77002 (fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) 20606 includes ultrasound guidance. DO NOT use for fluoro guidance Intermediate Joint Injections Image- 08/30/16 MMG, 2001 eorthopod.com

20610- Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, ship, knee, sub acromial bursa); with ultrasound guidance 20611- with ultrasound guidance, with permanent recording and reporting 20610- DO NOT report with 76942. If fluoro used- 77002 20611 includes ultrasound guidance. DO NOT use for fluoro guidance Major Joint Injection Image- 08/30/16 fpnotebook.com

Viscous Supplementation J7325- Hyaluronan or derivative, Synvisc or Synvisc-One, for intra- articular injection, 1 mg Synvisc 48 mg injected = 48 units J7324- Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose J7321- Hyaluronan or derivative, Hyalgan or Supartz, for intra- articular injection, per dose Viscous Supplementation

JW Modifier- MLN Matters MM9603 Currently use of JW modifier is at the MAC’s discretion. Use of JW modifier required for claims with unused drugs or biologicals from a single use vial or single use package. Must document the discarded drug or biological in the patient’s medical record when submitting claims with unused Part B drugs or biologicals JW Modifier- MLN Matters MM9603

Botox Example J0585 onabotulinum toxin A J0585 – 155 Units 155 units administered 45 units wasted J0585 – 155 Units J0585- 45 Units –JW modifier https://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network- MLN/MLNMattersArticles/Downloads/MM9603.pd Botox Example

Resources ICD 10 updates JW Modifier http://www.cdc.gov/nchs/icd/icd10cm.htm JW Modifier https://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNMattersArticles/Downloads/MM9603.pd Resources