1. Ouch! Pain Management Coding
Chris Lam, CPC, CASCC
AAPC Martinez

2. Outline Introduction Anatomy Epidural Injection
Transforminal Injection
Facet Injection
Facet Denervation

3. 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)

4. 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

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

6. 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)

7. Tip: Even Digit = Without; Odd Digit = With
Without Guidance
With Guidance
C/T
62320
62321
L/S
62322
62323
Do not code or with guidance codes (77003, 77012, 76942) because it’s inclusive.
Catheter placement for more than 1 day should be coded in 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

8. 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

9. 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

10. 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

11. 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)

12. 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!!

13. 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

14. 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

15. 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

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

18. 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

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

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

21. 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