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Coding and Documentation Tips for Spinal Injections

Mary LeGrand, RN, MA, CCS-P, CPC

In recent years, the American Medical Association’s Current Procedure Terminology (CPT) deleted the mainstay facet joint injection codes (64475–64479) and introduced the “all-inclusive” paravertebral facet joint injection codes 64490–64495. These new codes are part of the transition from component coding to the combination codes. Understanding the code changes, when services can be reported independently, and when the new combination codes must be used is critical.

Steps to coding spinal injections
The following steps should be taken in coding spinal injections:

  • Choose the code for the primary procedure. (Is the code an inclusive code or not?)
  • Choose the code(s) for any secondary procedures (such as an add-on code, or a code indicating the same procedure at a different level).
  • Is a radiology code needed? Is the use of image guidance bundled into the procedure code description, or is the radiology service separately reportable?
  • Where is the service performed? If the procedure is performed in a facility and radiology services are separately reportable, modifier 26 should be appended to the radiology code to reflect the work associated with the professional component only. If the procedure is performed in a procedure room in a physician’s office and radiology is not bundled into the surgical procedure code, the global radiology code is reportable without modifiers.
  • Include the J code(s) for injectable medication(s) if the medication expense is incurred by the practice. Be sure that the documentation includes the specific drug and concentration. (For example, 40 mg of ABD drug was injected, rather than 4cc ABD.)

Procedure notes
By definition, spinal injections are invasive procedures and require either an operative or a procedure note, depending on where the procedure is performed. Typically, a full operative note is documented if the procedure is performed in a hospital or an Ambulatory Surgery Center (ASC). When the service is performed in an office setting, an “operative-style note” is acceptable, but most physicians use a detailed procedure note.

The documentation must include the following:

  • The type of injection—what medication is being injected? The 2012 guideline changes related to CPT codes 64600–64681 state that these codes include the injection of other therapeutic agents (eg, corticosteroids). Diagnostic/therapeutic injections should not be reported separately.
  • Injection location: anatomic structure, unilateral versus bilateral
  • Whether a catheter was used
  • Whether fluoroscopy, computed tomography (CT), or ultrasound guidance was used, versus a formal contrast imaging study such as epidurography

Radiology reports
A separate report is required whether the physician is performing a formal contrast study such as an epidurography (72275) or injecting contrast for fluoroscopic guidance (77003). Both services contain Relative Value Units for the professional interpretation (modifier 26) and the technical component. For this reason, the rules associated with radiology coding require a professional interpretative report.

CPT code 72275 should be used only when an epidurogram is performed, images documented, and a formal radiologic report is issued.

Coding examples
The following examples show how the new codes should be applied.

Paravertebral facet injection: The surgeon performs a lumbar paravertebral facet injection at L4-5 using fluoroscopic imaging in a patient with chronic back pain and disk disease. The surgeon documents the following: the injection site (right L4-5 facet joint), the injection of contrast and needle localization, and the injection of the steroid/anesthetic drugs. The drug documentation contains the specific drug and milligram and/or dose concentration. The procedure is performed in the office setting.

Coding is as follows:

  • 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
  • J code(s)—The J codes are reported for the drugs injected because the procedure is performed in the office location.
  • A or Q code(s)—Contrast material

CPT code 77003 is not separately reportable because the injection code 64490 includes the use of image guidance in the code description. Use of image guidance and documentation of such is key in reporting 64490. In the absence of image guidance, the correct CPT code would be 20552 or 20553 (trigger points). Drugs and contrast material are reportable based on office location place of service.

CPT codes 64490–64495 describe the work associated with fluoroscopic or CT guidance. Report codes 0213T–0218T, as appropriate, for paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance as appropriate for the specific anatomic location.

Epidural injection: The surgeon performs an epidural injection at L4-5 in a patient with chronic back and leg pain. The documentation states that fluoroscopic guidance was used for needle placement, and that contrast was injected, and it was confirmed that the needle tip was in the epidural space. Steroid injection was performed. The procedure was performed in the ASC.

Coding is as follows:

  • 62311—Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic.
  • 77003-26—Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid).

Fluoroscopic imaging is separately reportable because the injection code does not include the image guidance in the description. Because the procedure was performed in a facility setting, CPT code 77003-26 is reported for the professional interpretation only. For the same reason, the drugs are not reportable by the physician.

Action steps

  • Ensure all key elements are fully documented to ensure accurate coding.
  • Review payer policies for any other requirements or limitations, such as additional documentation, medical necessity coverage, or administration frequency.
  • Update encounter forms, surgical scheduling sheets, and other tools to capture the code changes for accurate claim submission.
  • If denials occur, review the Explanations of Benefits from payers to identify any problems or issues.
  • Ensure accurate claim submission of drugs by using the National Drug Code directory and providing additional dose information if required.
  • Consider an external compliance coding review.

Mary LeGrand, RN, MA, CCS-P, CPC, is a senior consultant with KarenZupko & Associates, Inc. This article has been reviewed and approved by members of the AAOS Coding, Coverage, and Reimbursement Committee.

AAOS Now
April 2012 Issue
http://www.aaos.org/news/aaosnow/apr12/managing1.asp