Ouch! Pain Management Coding Chris Lam, CPC, CASCC cklam89@gmail.com AAPC Martinez

Outline Introduction Anatomy Epidural Injection Transforminal Injection Facet Injection Facet Denervation

Introduction What is Pain Management? Specialty that focuses on management of pain through various therapeutic plans and treatments. We will focus on Epidural and Transforminal Injections, as well as Facet Injection and Denervation. One of the four biggest outpatient specialties (along with ophthalmology, orthopedics and GI)

The Spinal Cord is separated by 4 sections: Spinal Cord Anatomy Codes are determined by the type of injection, nerve selection, and anatomic location of the spine. The Spinal Cord is separated by 4 sections: Cervical C1-C8 Thoracic T1-T12 Lumbar L1-L5 Sacral S1-S5

Epidural Injection Interlaminar, Translaminar, ESI, Standard Epidural Diagnostic/Therapeutic Common diagnostics: Disc displacement, Spinal Stenosis, Radiculitis

Expanded from 2 CPT Codes to 4 CPT Codes!! New Codes for 2017!! Expanded from 2 CPT Codes to 4 CPT Codes!! CPT: Cervical and Thoracic 62320: Injection(s), of diagnostic or therapeutic substance(s) (eg, 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 62321; with imaging guidance (ie, fluoroscopy or CT) Lumbar and Sacral 62322: Injection(s), of diagnostic or therapeutic substance(s) (eg, 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 62323; with imaging guidance (ie, fluoroscopy or CT)

Tip: Even Digit = Without; Odd Digit = With Without Guidance With Guidance C/T 62320 62321 L/S 62322 62323 Do not code 62321 or 62323 with guidance codes (77003, 77012, 76942) because it’s inclusive. Catheter placement for more than 1 day should be coded in 62323-62327 range. Multiple injection can not be coded for bilateral, multiple injection of the same level or region. Epidural injection diffuses into the entire epidural space, thus eliminates the necessity of injection of both sides to achieve the same effect. Code is described per region, not per vertebral segment or interspace. Without guidance is possible; loss of resistance Code based on the region at which the needle or catheter entered the body. Not moving catheter tip nor medication moving into another region

SUBARACHOID SPACE – CSF Subarachnoid Injection: Different procedures, but same CPT descriptions as Epidural Injection. Code base on level of region and with/without guidance SKIN FAT MUSCLE LIGAMENTS EPIDURAL SPACE ARACHNOID SUBARACHOID SPACE – CSF SPINAL CORD

Caudal Space Injection: Different procedures, but same CPT descriptions as Lumbar Epidural Injection. More difficult and requires more medication volume than a simple epidural injection (2cc vs 10-15cc) Targets most Sacral region. Code base on with/without guidance

Transforminal (Epidural) Injection Selective nerve root block, SNRB, selective epidural, TFESI Foramina: The opening between two vertebrae through which spinal nerves leave the spinal cord on the right and left side of the body, and extends to other parts of the body Common diagnostics: Disc herniation, Spinal Stenosis, Radiculitis

CPT: Cervical and Thoracic 64479: Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level +64480; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Lumbar and Sacral 64483: Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level +64484; lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Additional Information Regarding TFEI Codes: Add-on codes must be pair with correct primary procedure. Codes are unilateral. Facilities and Professional differences Ultrasound codes specifically use 0228T-0231T 2014: CMS Does not allow separate payment for add-on codes CMS limited coverage of CAT III Codes T12-L1: Use C/T Documentation of Interspace vs Nerve Roots is very important!!

Documentation: Interspace vs Nerve Roots Vertebral Interspace Level Spinal Nerve Root that exits at this level Base of Skull (C0) – C1 C1 C1-C2 C2 C2-C3 C3 C3-C4 C4 C4-C5 C5 C5-C6 C6 C6-C7 C7 C7-T1 C8 Vertebral Interspace Level Spinal Nerve Root that exits at this level T1-T2 T1 T2-T3 T2 T3-T4 T3 T4-T5 T4 T5-T6 T5 T6-T7 T6 T7-T8 T7 T8-T9 T8 T9-T10 T9 T10-T11 T10 T11-T12 T11 T12-L1 T12 Vertebral Interspace Level Spinal Nerve Root that exits at this level L1-L2 L1 L2-L3 L2 L3-L4 L3 L4-L5 L4 L5-S1 L5 S1 Foramen S1 S2 Foramen S2 S3 Foramen S3 S4 Foramen S4 Near Sacro-Coccygeal Joint S5

Guess how many injections? Poor Documentation Guess how many injections? “Injection at L1-L2-L3” Ideally you want to correct the physician dictation habits. Interpreted as (1) L1-L2 Interspace and (2) L2-L3 Interspace “Injection at L1, L2, L3” Interpreted as (1) L1 (2) L2 (3) L3 Nerve Roots L1-L2 L1 L2 L3 L4 L2 L3 L4 L2-L3 L3-L4 L4-L5

L2 L3 L4 Better Documentation Guess how many injections? L1-L2 L2-L3 “TFESI at interspace L1-L2, and L2-L3” L1-L2 Interspace and (2) L2-L3 Interspace 64483, 64484 “TFESI at nerve root L1, L2 and L3” (1) L1 (2) L2 (3) L3 Nerve Roots 64483, 64484, 64484 L1-L2 L1 L2 L3 L4 L2 L3 L4 L2-L3 L3-L4 L4-L5

Facet Joint Injection Also known as paravertebral spinal, medial branch block, MBB, , scottie dog Diagnostic/Therapeutic Common diagnostics: Spondylosis, Facet Joint Syndrome

For ultrasound guidance, use CAT III codes 0229T-0230T CPT: Cervical and Thoracic 64490: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level +64491; second level (List separately in addition to code for primary procedure) +64492; third and any additional level(s) (List separately in addition to code for primary procedure) Lumbar and Sacral 64493: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level +64494; second level (List separately in addition to code for primary procedure) +64495; third and any additional level(s) (List separately in addition to code for primary procedure) For ultrasound guidance, use CAT III codes 0229T-0230T

Facet Joints are labelled between vertebras T12-L1 Facet Joint, use C/T If no imaging is used, see code 20552-20553 Ultrasound guidance, use CAT III codes 0213T-0218T The 64492 and 64495 can only be reported once regardless how many more levels than 3 are injected per region. Diagnostic also sets up Facet Denervation.

Facet Denervation Radiofrequency Neurotomy, RFA, Medial Branch Neurotomy, Radiofrequency Denervation

If RF is <80 C, then you must use CPT 64999 Cervical and Thoracic 64633: Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint +64634; cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) Lumbar and Sacral 64635: Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint +64636; lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) If RF is <80 C, then you must use CPT 64999