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Conference Name: Pain Management: Coding for Spinal Block and Nerve Destruction Scheduled Conference Date: Thursday, November 18, 2004

Scheduled Conference Time: 1:00 p.m.–2:30 p.m. (Eastern), 12:00 p.m.–1:30 p.m. (Central), 11:00 a.m.– 12:30 p.m. (Mountain),10:00 a.m.–11:30 a.m (Pacific); 9:00 am - 10:30 am ADT (Alaska)

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Pain Management:

Coding for Spinal Block

and Nerve Destruction

A 90-minute interactive audioconference

Thursday, November 18, 2004

1:00 p.m.–2:30 p.m. (Eastern)

12:00 p.m.–1:30 p.m. (Central)

11:00 a.m.–12:30 p.m. (Mountain)


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Copyright 2004, HCPro, Inc.

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Thank you for participating in our Pain Management: Coding for Spinal Block and Nerve Destruction audioconference with Lolita M. Jones, RHIA, CCS, and Alison Nicklas, BS, RHIT, CCS, and moderated by Brian Murphy.

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Agenda . . . .vi

About your sponsors . . . .vii

Speaker profiles . . . .viii

Exhibit A . . . 1

Presentation by Alison Nicklas, BS, RHIT, CCS and Lolita M. Jones, RHIA, CCS


. . . .



1. Overview

2. Case study for injections

• Official guidelines

• Real life scenarios with the correct approach

3. Case study for nerve destruction

• Official guidelines

• Real life scenarios with the correct approach

4. Case study for epiduralgram

• Official guidelines

• Real life scenarios with the correct approach

5. 2005 CPT update


About HCPro, Inc.

HCPro is the premier healthcare information and resource provider on compliance and regulatory issues faced by hospitals, home health organizations, nursing homes, physicians’ offices, and other healthcare facilities. HCPro has launched a number of Web “supersites” that include tips, how-to information, “ask the expert columns,” free e-mail newsletters, and so much more.

About Brefings on APCs

Created exclusively for HIM directors, coding supervisors, Medicare reimbursement directors, directors of ambulatory care and outpatient services, and other HIM professionals, Briefings on APCs helps facilities understand the complexities of the changing rules under OPPS and APCs

and the impact they will have on hospital HIM systems and processes, including coding, documentation, and billing.

Subscribers receive the latest information about

• understanding the basics of OPPS and APCs • techniques for correct coding

• continued education for staff

• APCs and OPPS in your emergency department • the financial impact of APCs

• compliance under OPPS and APCs

• analysis of the impact of HCFA program memos


Alison Nicklas, BS, RHIT, CCS

Alison Nicklas, BS, RHIT, CCS, is the director of education and training for Precyse Solutions. Nicklas has been

in this position for the past three years, researching, developing, and providing education for company col-leagues and clients in the areas of ICD-9-CM, DRG, CPT, HCPCS, APC, and billing, and compliance issues. Prior to this, she performed coding and auditing assignments as a consultant and was the director of medical records at two upstate New York acute-care hospitals. She has a bachelor’s degree in healthcare administration and is certified by AHIMA as an RHIT and CCS.

Lolita M. Jones, RHIA, CCS,

Lolita M. Jones, RHIA, CCS, is the principal of a consulting practice that advises the Center for Substance Abuse

Treatment and SAMHSA about the transaction standards and code-set requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Jones recently launched her web-based coding programs at

www.EZMedEd.com. She also served as the editor and cowriter for Reimbursement Methodologies for

Healthcare Services (published by the America Health Information Management Association). Her latest book is

the Modifier Clinic: A Guide to Hospital Outpatient Issues, published by HCPro, Inc., in Marblehead, MA.. Jones

specializes in hospital outpatient and ambulatory surgery center coding, billing, reimbursement, and operations and is based in Fort Washington, MD.


Pain Management Coding


Spinal Block Injections,




This program is being presented to provide you with important information addressing coding guidelines specific to spinal pain injections, nerve destruction and epidurograms while also providing you with real-life case scenarios to aid in the understanding of appropriate code assignment.

Issues that have been found in coding these types of cases include a

misunderstanding of guidelines and lack of demonstrated medical necessity for the procedures in question. Our goal is to provide you with documentation and examples to help you and your coding staff make informed choices in code selection for appropriate and complete reimbursement.


Case Study for Injections

CPT Coding Guidelines Injections

The facet joint is located on the posterior aspect (back) of the spine, on either side of the vertebrae, overlapping the neighboring vertebrae. This joint provides stability to the spine and gives it the ability to bend and twist. A thick layer of cartilage separates the two surfaces of adjacent vertebrae – making up the joint. Surrounding the facet joint is a sac-like capsule that is filled with synovial fluid. This fluid lubricates the bone surfaces, reducing friction when the spine moves and also provides nourishment to the cartilage.

There are two main reasons for undergoing a facet joint injection:

Diagnostic – to determine the cause of pain – pain, which has continued for

more than six weeks – and for which conservative treatment has not been effective and/or the pain has increased.

Therapeutic – to treat an abnormality

The physician may suspect that the facet joint is the root cause of persistent pain when there is no radicular component involved, there is no associated neurologic deficit , and hyperextension of the spine – due to standing or walking –

aggravates the pain. An MRI or a CT scan may be performed to determine if there is any inflammation, irritation, swelling or arthritis in the facet joint.

Additionally, if the facet joint is the cause of pain, an injection or “block” may be ordered. In the performance of this procedure, a needle is placed in the facet joint or at the median branch nerve under fluoroscopic guidance and a long acting local anesthetic agent and/or corticosteroid is injected in the joint or at the nerve to temporarily denervate the facet joint. After a satisfactory “block” of the pain has been obtained, the patient is asked to perform the activities that usually aggravate the pain and to record his/her impressions of the effect of the

procedure 4-8 hours after the injection. This type of block is considered to be a “diagnostic” injection.


Once it is determined that the facet joint is the source of the pain, therapeutic injections of anesthesia and anti-inflammatory medications can provide pain relief for longer periods of time.


Based on the Local Carrier Determinations for Medicate, there are specific indications for the performance of an injection of this type. As stated:

“Chronic pain is defined as pain, which has been present for six months or more. The indications for any nerve block appropriately begin with a sequential diagnostic evaluation of chronic pain. A thorough history and physical exam highlighting the type, severity, exacerbating factors, medical as well as psychological disorders, is assumed. If the patient fails traditional aggressive analgesic therapy, or the etiology of the pain is uncertain, nerve block may play a pivotal role both diagnostically and therapeutically.”

Diagnostic Block

A nerve block can provide specific answers, based on careful evaluation, as to the cause of chronic pain. When placed appropriately, a definitive answer may be determined in the following situations:

1. To establish the exact diagnosis when considering a differential diagnosis 2. When there is a discrepancy between demonstrated pathology and the

complaints or findings.

3. Multiple sources of pain are present

4. When it is unclear if the pain is central or peripheral in origin 5. To differentiate between visceral pain and that of skeletal origin 6. A paravertebral block can help when:

a. Pain appears to be due to classic mono-radiculopathy and neuro-diagnostic studies fail to provide structural explanation

b. Pain is classically monoradicular with radiological studies demonstrating abnormality relating to adjacent nerve root – indicating an anatomic variation

c. The clinical picture is suggestive but not typical for both nerve root and distal nerve or joint disease.

Therapeutic Block

A therapeutic block can be used to treat radicular pain or severe pain that is confined to a distinct region of the body. In some cases, the nerve block is combined with steroids. A paravertebral nerve block includes the placement of the tip of the injecting needle adjacent to the lateral margin of neuroforamen with the aid of fluoroscopic imaging, allowing a selective, reproducible blockage of a specific nerve root with a small amount of anesthetic agent. This procedure can be performed on any nerve root from C-2 through S-5.

In the therapeutic setting, it may be necessary to complete a series of injections to establish consistency of results, particularly if the diagnostic blocks are


followed by neurolysis. If the injections are successful, a series of injections may be reasonable in the event of relapse. However, long term, multiple blocks, over a period of several weeks or months is not considered to be an effective method of chronic pain management and may not be determined to be medically

necessary or appropriate.


In considering the efficacy of a nerve block injection, the following limitations are applied by Medicare:

1. Radiculopathy should be ruled out by physical/electrophysiologic examination.

2. Acupuncture may not be billed as a facet joint nerve block.

3. "Non-invasive neuron blockade" devices, "electroceutical neuron blockade", devices or "bioelectric treatment systems" may not be billed as facet joint nerve blocks.

4. Transcutaneous nerve stimulator or any other nerve stimulator may not be billed as a facet joint nerve block.

5. Anesthesia billed in addition to a facet joint nerve block is considered not reasonable and necessary.

Appropriate CPT Codes

When assigning codes to a nerve block injection, it is necessary to include a code for the medication – up to two – as well as a code for the injection – in the 64470-64476 range, and, when documented, a fluoroscopic guidance code.

The following table provides the code options for this reporting a nerve block:

J-Code Anesthetic agent used

J-Code Steroid - if used in addition to anesthetic 64470

Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level

+ 64472

cervical or thoracic, each additional level (list separately in addition to code for primary procedure)

64475 lumbar or sacral, single level + 64476

lumbar or sacral, each additional level (list separately in addition to code for primary procedure)

Medical Necessity

To obtain reimbursement for a nerve block procedure, documentation must demonstrate medical necessity with proper ICD-9-CM diagnosis code assignments. In addition to linking the procedure code to the correct and payable ICD-9-CM code, the diagnosis or clinical signs/symptoms must be present and documented for payment. In addition, these ICD-9-CM codes can only be used as noted above in the “Indications” and “Restrictions” paragraphs.


721.0 Cervical spondylosis without myelopathy 721.2 Thoracic spondylosis without myelopathy 721.3 Facet Arthropathy

722.81 Postlaminectomy syndrome, cervical region 722.82 Postlaminectomy syndrome, thoracic region 722.83 Postlaminectomy syndrome, lumbar region

723.1 Cervicalgia

724.1 Pain in thoracic spine 724.2 Lumbago

724.8 Facet Syndrome

Required Documentation

1. ICD-9-CM code must be submitted reflecting patient condition and indicate reason for procedure.

2. If an ICD-9-CM diagnosis code reported is not found on the accepted list, the physician must document medical necessity with rationale for the service provided in the record.

3. Documentation should demonstrate process used to determine suspected diagnosis – for example providing a detailed description of the type of pain. 4. Any pre-operative evaluation performed that led to the suspected pathology

along with post-operative conclusions.

5. Fluoroscopic guidance must be performed to ensure the safety and accuracy of the procedure – and must be documented in the record.

6. Documentation of the procedure must be made available to Medicare upon request.


1. Each facet joint is considered to be one level, one side. If an injection was performed on each side, it is considered to be a bilateral injection and the appropriate modifier (-50) must be appended. (If performed on one side only, use the –LT or –RT modifier.) If any more than six injections are performed within 180 days, the additional injections will be denied coverage. (6 unilateral, 3 bilateral, or any combination thereof.)

2. Only one type of block/injection may be performed in a given session – to determine effectiveness of treatment prior to attempting another type. 3. Performance of a facet joint nerve block on more than one level during the


4. Facet joint injections should not be administered more often than one very two to four weeks in the same spinal level – allow at least two-week intervals between injections to allow the effects of the medication to start to work.

CPT Assistant – Resources

September 2004 – “The Facts of Paravertebral Facet Joint Procedures (64470-64476, 64622-64627)

1. Codes 64470-64476 should be reported per spinal level.

2. There are 4 facet joints associated with each single vertebrae – two articulate with the vertebrae above, two articulate with the vertebrae below.

3. Each facet joint has dual innervation. This may mean that multiple-level injections may be necessary for the proper evaluation and management of chronic pain.

4. Use modifier –50 when a bilateral injection is performed.

5. Modifiers 51 and 59 are inappropriate to use with 64472 and 64476 – these are add-on codes and exempt from multiple procedure concept.

6. Code selection depends on the location of the injection – cervical, lumbar, or spinal – procedures are more difficult depending upon the location.

7. Report codes 64475 and 64475 and 64479 and 64480 once only regardless of the number of punctures required or the number of drug(s) injected at that specific level.

8. Report x-ray fluoroscopic guidance code 76005 when performed in conjunction with codes 64470-64475 – by region, not per level. 9. Injection of contrast material is inclusive to codes 64470-64476 – not

separately reported. 10.

NOTE: Coding Tips from September 2004 CPT Assistant:

• “Third-party payers may have specific reporting guidelines for ICD-9-CM diagnosis reporting associated with facet joint nerve and facet joint injection procedures. Therefore, it is best to check with third-party payers for individual policies.”

• “Code 76005 is intended to be reported per spinal region (eg, cervical, lumbar) and not per level


Case Study 1: 62311 , 62311-59, 76005


PREOPERATIVE DIAGNOSIS: Degenerative disk disease at L3-4 and L4-5.

POSTOPERATIVE DIAGNOSIS: Degenerative disk disease at L3-4 and L4-5.

PROCEDURE: Lumbar epidural steroid injections at L3-4 and L4-5,

translaminar approach, with radiographic guidance.

INDICATIONS FOR PROCEDURE: Mr. K. underwent epidural injections at L3-4 and

L4-5 on July 9, 2004, with significant relief of his low back pain. He continues to be improved but feels that the pain is returning somewhat at this time. He is on physical therapy. We have decided to repeat the procedure that was performed approximately seven weeks ago to give the patient relief so that he may continue with physical therapy. He understands the procedure and gave his informed consent.

OPERATIVE REPORT: The patient was placed in the prone position. His back was prepped with a Betadine solution and draped in a sterile fashion. He was sedated with intravenous midazolam. Using fluoroscopy, the lumbar spine was identified. There are five non-rib-bearing lumbar vertebrae. Both the L3-4 and L4-5 interspaces were anesthetized with 1% lidocaine. An 18-gauge epidural was advanced with lateral fluoroscopy into the epidural space at a depth of approximately 9 cm. Injection of 80 mg of Depo-Medrol with 2 cc of sterile saline was performed. The needle was withdrawn and a sterile dressing was placed over the insertion site. At the L4-5 level, the procedure was repeated, and again 80 mg of Depo-Medrol with 2 cc of sterile saline were injected at the L4-5 interspace. All needles were removed intact. A sterile dressing was placed over the insertion sites. The patient was discharged with stable vital signs. He will follow up me on an as-needed basis.


Case Study 1: 62310, 62311, 76005-59, 76005-59


PREOPERATIVE DIAGNOSIS: Cervical and lumbar radiculopathy.

POSTOPERATIVE DIAGNOSIS: Cervical and lumbar radiculopathy.

PROCEDURE: Cervical and lumbar epidural steroid injections with radiographic guidance.

INDICATIONS FOR PROCEDURE: Vivian underwent a lumbar epidural steroid injection on August 17, 2004, with minor relief of pain which she had been experiencing in her low back. We had planned to performed a cervical epidural steroid injection today with fluoroscopy, but given the patient's lack of significant response in the low back, we will repeat the lumbar epidural steroid injection today as well. She understands both procedures and gave her informed consent.

OPERATIVE REPORT: The patient was placed in the prone position. The patient’s neck was prepped with a Betadine solution and draped in a sterile fashion. The cervical spine was identified under fluoroscopy. There are 7 cervical vertebrae in good

alignment. The C5-6 level was identified, and using a 25-gauge, 1_-inch needle, the skin and subcutaneous tissues were anesthetized with 5 cc of 1% lidocaine. An 18-gauge epidural needle was advanced under fluoroscopy into the epidural space without incident to a depth of 6 cm. Injection of 2 cc of Isovue-200 dye was injected, and contrast was seen to spread in both a cephalad and caudad fashion. Next 80 mg of Kenalog followed 2 cc of sterile saline were injected via the needle. The needle was removed intact, and a sterile dressing was placed over the insertion site. There was no blood, CSF, or

paresthesia encountered. The patient was placed in the prone position. The patient’s back was prepped with a Betadine solution and draped in a sterile fashion. Fluoroscopy was used throughout the procedure. The L4-5 level was identified under fluoroscopy. This interspace was anesthetized with 5 cc of 1% lidocaine using a 25-gauge, 1_-inch needle. An 18-gauge epidural needle was then advanced under fluoroscopy into the epidural space to a depth of 6.5 cm. There was no blood, CSF, or paresthesia

encountered. Then 2 cc of Isovue-200 contrast was injected via the needle. Epidural spread of contrast was appreciated in a cephalad and caudad fashion. Next 80 mg of Kenalog with 2 cc of sterile saline was injected via the needle. The needle was removed intact, and a sterile dressing was placed over the insertion site.

The patient was discharged with stable vital signs. She was given instructions to follow up with me in approximately two weeks in my downtown office.


Case Study 3: 64475-50, 64483-LT, 76005


PREOPERATIVE DIAGNOSIS: Lumbar radiculopathy.

POSTOPERATIVE DIAGNOSIS: Lumbar radiculopathy.

PROCEDURE: 1. L4-5 facet joint injections with radiographic guidance.

2. Left L3 transforaminal epidural steroid injection with radiographic guidance.

INDICATIONS FOR PROCEDURE: The patient is a pleasant 70-year-old female with chronic low back pain and left leg pain. An MRI dated July 26, 2004, revealed prominent facet arthrosis at L4-5 with early degenerative grade 1 anterolisthesis, disk bulging, and mild narrowing of each lateral recess. A shallow, broad-based, leftward disk protrusion at L3-4 abuts the L3 and L4 nerve roots. These findings are consistent with her pain complaints. She and I discussed performing bilateral L4-5 facet injections, as well as a left L3 transforaminal epidural steroid injection. She understands the risks, benefits, and alternatives to the procedure, and she gave her informed consent.

OPERATIVE REPORT: The patient was placed in the prone position. Her back was prepped with a Betadine solution and draped in a sterile fashion. Fluoroscopy was used throughout the procedure. There are 5 non-rib-bearing lumbar vertebrae. The L4-5 facet joints were targeted, and the skin and subcutaneous tissues along these lines were anesthetized with 1% lidocaine. Then 22-gauge, 3_-inch spinal needles were advanced into the joints bilaterally. Injection of 20 mg of Depo-Medrol and 1 cc of 0.25% bupivacaine was performed. The needles were removed intact. A 22-gauge, 66-inch spinal needle was advanced into the left L3 neural foramen at its superior posterior aspect. Correct needle placement was confirmed in AP, lateral, and oblique views. An injection of 80 mg of Depo-Medrol and 2 cc of 0.25% bupivacaine was performed. All needles were removed intact. Sterile dressings were placed over the insertion sites.


Case Study 4: 62290, 62290, 62290, 72295, 72295

Preoperative diagnosis: Low back pain. Postoperative diagnosis: Low back pain.

Operation: L3-L4, L4-L5, L5-S1 Discography. Surgeon:

Referring physician: Instrument:

Anesthesia: IV Sedation. Blood Loss: Minimal. Complications: None.

History: Mr. reports 5/10 pain in the lower back. It is still achy and aggravated by prolonged sitting. It does not radiate to the lower extremity. He has had lumbar facet blocks and radiofrequency thermocoagulation, and the pain persists. On physical exam he has full motor strength and intact sensation to light touch in the lower extremities.

Procedure: Informed consent and agree to the risks of bleeding, infection, nerve injury, paralysis, increased pain, failure to relieve pain permanent or temporary, headache, reaction to medications, numbness, and weakness. All questions were answered, options explained. N.p.o. status confirmed. IV placed. In the prone position, the back was prepped and draped. Lidocaine 2% 18 cc was used for local anesthesia, using a #27 gauge 1.25 inch needle. Under fluoroscopic guidance, a 5 inch #22 gauge needle was inserted first at L3-L4, and a second one at L4-L5 disc, and at the L5-S1 disc the #22 gauge introducer followed by 6 inch needle placed at L5-S1. At each of these three levels Omnipaque 300 0.4 cc was given. Each injection did not reproduce his pain. Versed 2mg was given in divided doses for sedation.

ASSESSMENT AND PLAN: His discography will be followed up by a CT scan to detect if any annular tears are present. None were noted on injection in the operating room. If an annular tear is noted he would be a candidate for either nuclear plasty or an intra-disc electro-thermocoagulation. Thank you for this referral.


Case Study 5: 64418

Preoperative Diagnosis: Right shoulder pain.

Postoperative Diagnosis: Right shoulder pain.

Operation: Right suprascapular nerve block Surgeon:

Referring Physician: Instrument:

Anesthesia: IV Sedation. Blood Loss: Minimal. Complications: None.

HISTORY: Dr. Eason has had persistent right neck, right shoulder, and right greater than left scapular pain. The pain is a 7/10 sore achy pain. On physical exam she has full range of motion in the right and left shoulder, abduction, and forward flexion. There is full motor strength of the upper extremity with intact sensation to light touch. There is an inconsistent right Tinel’s sign over the suprascapular notch.

PROCEDURE: Informed consent and agree to this risks of bleeding, infection, nerve injury, paralysis, increased pain, failure to relieve pain permanent or temporary, headache, reaction to medications, and pneumothorax. All questions were answered, options explained. N.p.o. status confirmed. In a sitting position her right scapular area was prepped and draped. Lidocaine 2% 1 cc was used for local anesthesia, using a #27 gauge 1.25 inch needle. Under fluoroscopic guidance, a 3.5 inch #25 gauge needle was inserted right at the right suprascapular notch. Then 4cc 0.5% bupivacaine was given. A pain diary was given.

ASSESSMENT AND PLAN: Dr. Eason suffers from chronic right scapular pain, and I have spoken to her following the injection. Her pain had diminished so I will repeat this with steroids. Thank you for this referral.


Case Study 6: 64421, 9921X


HISTORY OF PRESENT ILLNESS: The patient is an 81 year old female who is being referred for evaluation of post herpetic neuralgia. Ms. suffered an acute attack of herpes zoster approximately four months ago which was followed by persistent pain. The pain is located on the left side of her body. It proceeds from the left paravertebral space along the T8-T10 area and tracks to the anterior abdomen along the same dermatomes. There are no blisters or persistent lesions present; however, she does have scarring from the virus. She says that the pain is quite severe.

PAST MEDICAL HISTORY: She also has a significant medical history consisting of atrial fibrillation and previous congestive heart failure due to rheumatic heart disease. She has hypertension and non-Insulin dependent diabetes mellitus. She denies any angina or previous myocardial infarctions. She also denies any bowel or bladder dysfunction.

PAST SURGICAL HISTORY: She has had surgery in the past consisting of cholecystectomy, right mastectomy in 1994, and bilateral cataract extractions.

MEDICATIONS: She has been taking Coumadin which was discontinued four days prior to this date of consultation. PT and PTT were obtained today; both of which were normal. Her current medications are Glucatrol, Vasotec, Lanoxin, Lasix, Potassium Chloride, Tamoxifen, and Darvocet on a p.r.n. basis.

Allergies: Her only allergy is to IVP dye.

PHYSICAL EXAMINATION: General appearance is that of a very pleasant,

cooperative female in mild distress. She does appear younger than her stated age. Vital Signs – Blood pressure, 136/73; pulse, 84, irregular; respirations, 20. Her height is 5’51/2”. Her weight is 164 pounds. Her lungs are clear to auscultation. Cardiac exam reveals an irregular rhythm. She has a significant systolic murmur that radiates to the axilla and is heard best in the second intercostal space.

On examination of her trunk, she has the well healed lesions status post the herpes zoster along the T-8-T10 dermatomes. She is quite tender to palpation along that area;


Case Study 6



1) Post Herpetic Neuralgia. 2) Rheumatic Heart Disease.

3) Atrial Fibrillation secondary to No. 2.

4) Previous Congestive Heart Failure Secondary to No. 2. 5) Hypertension.

6) Non-Insulin Dependent Diabetes Mellitus. 7) Status Post Mastecomy for Carcinoma.

PLAN: As Ms. has discontinued her anticoagulant medication for four days and her PT and PTT are in the normal range today, she is a candidate for a block. I have considered the options of whether she should have intercostal block versus the epidural sympathetic block, and have decided at this point that intercostal nerve block would be her best option considering the fact that she does have significant cardiac disease and a sympathectomy would be less well tolerated under that given condition. If for some reason, the intercostal nerve block does offer significant improvement, then consideration as a second mode would be the epidural sympathetic block.

The intercostal block procedure and risks were explained to her in detail. The risks include possible lack of pain relief, possible pneumothorax requiring a chest tube, and also the risk of infection. She verbalized understanding and consented to proceed.

PROCEDURE: After the consent was obtained, the patient was placed in the right lateral position. A pillow was placed under her trunk on the right side. It was then cleansed with Betadine solution. Intercostal blocks were performed at the T8, T9, and T10 level using Marcaine 0.5% with Epinephrine 1:200,000. A 5 cc solution was injected at each site after careful aspiration. The needle was a 23 gauge 1.5 inch – needle.

She tolerated the procedure very well. There was no suggestion of pneumothorax or lung puncture during the procedure. A chest x-ray was obtained; after which, it confirmed that there was no pneumothorax. She has been given an instruction sheet and will be

discharged home in stable condition. I will schedule an appointment for her to return in two to three days to assess her response and either repeat the intercostal block or perform an epidural block, depending upon her response.


Case Study 7: 64510


Preoperative Diagnosis:

1. Reflex sympathetic dystrophy.

Postoperative Diagnosis:

1. Reflex sympathetic dystrophy.

Operation Performed:

1. Right stellate ganglion block #1.

Anesthesia: Local with sedation.

Informed Consent: The risks, benefits and limitations of stellate ganglion block were discussed with the patient including the risk of hematoma, epidural, spinal injection, Horner’s syndrome, hoarseness, difficulty swallowing and the limitation of the block to help the patient were discussed in detail along with the details of the procedure. The patient appeared to understand and agreed to proceed with the procedure.

Procedure in Detail: The patient was placed in the supine position. A #20 IV was started in his left hand. The patient was positioned on a shoulder roll with the neck extended. His neck was cleansed with Betadine and a #22, 1.5 cm needle was introduced

paratracheally at the level of the cricoid cartilage toward the stellate ganglion. The patient was unable to tolerate the procedure. The needle was withdrawn. The patient subsequently agreed to have sedation and then continue with the procedure. He agreed to have sedation and then continue with the procedure. He appeared to be very comfortable after titration of 4 mg of Versed intravenously and the procedure was reinitiated. The patient was given 10 cc of 0.5% Marcaine with epinephrine 1:200,000. The patient tolerated the injection well. There was no paresthesia, heme or CSF detected. The patient swallowed copiously during the procedure; however, we were able to obtain an adequate block with the patient’s right hand temperature changing from 90.1 F to 93 F after the block was done. The patient remained stable for the rest of his recovery. He was able to tolerate fluid and nutrition and was eventually discharged in stable condition with written instructions. He knows to call the Pain Clinic should there be concerns regarding the block today. He is to return to us in two days for further evaluation and additional block.


Case Study 8: 64475-50, 64476-50, 64476-50

Preoperative Diagnosis: L3-4, L4-5 and L5-S1 facet degenerative joint disease. Procedure: Left L3-4 facet injection, Right L3-4 facet injection. Left L4-4 facet injection. Right L4-5 facet injection Left L5-S1 facet injection. Right L5-S1 facet injection.

Postoperative Diagnosis: Anesthetist:

Anesthesia: 1% plain Lidocaine local. Estimated Blood Loss: Minimal.


Complications: None Path Specimen: None

Indications: This 56-year-old white female status post previous lumbar decompression has had back pain that has improved with intermittent facet injections. She presents for repeat facet injections. Because degenerative changes of the levels noted above, she will undergo bilateral facet injections.

Procedure: In the prone position, Betadine prep and draping, 1% Lidocaine was used to infiltrate the skin and subcutaneous tissue over the projected needle insertion sites. This was determined using C-arm fluoroscopy. Then, 22-gauge spinal needles were placed down to the L3-4, L4-5 and L5-S1 facets bilaterally. Each level on each side was then injected with an equal mixture from a total of 80 mg of Depo-Medrol, 10cc of 1% plain Lidocaine and 20 cc of 0.5% Marcaine without difficulty.


Case Study 9:

Medicare –

G0259 and 20610-59

Non-Medicare - 27096 and 20610-59

PREOPERATIVE DIAGNOSIS: 1. Right hip arthritis. 2. Right sacroiliac arthrosis.



1. Right hip steroid injection under fluoroscopy. 2. Right sacroiliac joint injection under fluoroscopy.


ANESTHESIA: Local with intravenous sedation/MAC.

INDICATIONS: See history and physical.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room on 12/10/03. After suitable analgesic and sedative effect had been achieved via intravenous sedation, the patient was placed into a prone position. While in a prone position, the contralateral left hip was bumped up to place the right SI joint perpendicular to the operating table. Fluoroscopic guidance was then utilized to place a 22-gauge spinal needle into the right SI joint inferiorly. A mixture of Xylocaine and Depo-Medrol was injected. The patient was then turned to a supine position. Then, 3-5 minutes time was allowed and her hip was examined. She had noted complete resolution of her posterior right hip pain at that point.

The right groin was then prepped and draped in the usual sterile fashion. The C-arm was utilized to localize the right hip. Again, a 22-gauge spinal needle was placed into the anterior inferior portion of the right hip and a mixture of Marcaine and Depo-Medrol was injected into the right hip. The needle was withdrawn and the hip was reexamined within 3-5 minutes. Her remaining right hip/groin pain had resolved in its entirety. She was returned to the recovery room in stable condition. There were no complications.


Case Study 9 continued

Sex: F

BD: 09/14/1953

Fluoroscopy < 1 hour ACC

ACC 1001 – FLUOROSCOPY < 1 HOUR - Dec 12, 2003


Approximately 36 seconds of fluoroscopy time were provided for Dr.

IMPRESSION: Fluoroscopy provided Dr. Interpreting Physician:



Case Study for Nerve


Nerve Destruction

At times, permanent nerve blocks may be recommended for the management of patients with chronic pain. The control of pain by the destruction of nerves (nerve root deadening) which carry pain signals is called neuroablation. The following describe nonsurgical nerve destruction:

• Injection of neurolytic substances, such as absolute alcohol, phenol or glycerin, performed under X-ray, and suitable for destruction of larger units like celiac plexus.

• Cryoanalgesia (the application of extreme cold to an affected nerve to deliberately disrupt its ability to transmit pain signals.) The degree of affect is controlled by the duration and intensity of the nerves exposure to the cold. Results range from minimal damage, causing loss of sensory function for several weeks, to full destruction of the nerve and sensory tissue, which causes complete loss of sensory function and possible motor impairment. This procedure is often used for chronic pain of the chest wall, face, and other neuralgias.

• Neurolysis (involving the use of a chemical agent to disrupt the function of a nerve by destruction of nerve tissues. The chemical (usually alcohol or phenol) is injected into a specific spinal nerve that serves or activates the painful area. The goal is to stop the nerve from sending pain signals to the brain. This procedure is usually effective in relieving pain for a period of weeks or months.

• Radiofrequency (RF) lesioning (applying high-frequency energy to produce heat and thermal coagulation of the affected nerves, disrupting their abilitly to transmit pain signals.) The RF energy is directed only at the affected nerve, which minimizes the risk of damaging adjacent nerves and tissues. This procedure can provide pain relief up to a year or more and is repeatable.

The freezing or burning of nerve roots may be temporary as they may grow back in 6 to 18 months, restoring sensation to the affected area.

Coverage Rules

When destruction of the facet joint nerve is performed following a nerve block, only the codes for the nerve destruction should be billed since their allowance include that of the facet nerve blockage procedure.

CPT Codes for Nerve Destruction


infraorbital, mental, or inferior alveolar branch (trigeminal – small branches)

64605 second and third division branches at foramen ovale (trigeminal 2/3 division)

64610 second and third division branches at foramen ovale under radiologic monitoring (trigeminal)

Radiofrequency ablation destruction would be reported using CPT codes 64622 Destruction by neurolytic agent, paravertebral facet joint nerve;

lumbar or sacral, single level

64623 lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

64626 cervical or thoracic, single level

64627 cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

76005 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction

Note: In general, fluoroscopic guidance is considered incidental to the

procedure being done. However, code 76005 will be allowed separately when reported with 27906, 62270-62282, 62310-62319, 64470-64484, 64622-64627.

CPT Assistant – Resources

September 2004 – “The Facts of Paravertebral Facet Joint Procedures (64470-64476, 64622-64627)

1. Assign codes 64622-64627 for nerve destruction.

2. Codes 64622-64627 are unilateral – append modifier 50 to indicate a bilateral procedure was performed.

3. 76005 is reported separately if fluoroscopic guidance and localization for needle placement and neurolysis is performed in conjunction with codes 64622-64627.

4. Codes 64622-64627 refer to individual nerve level destruction.

B. Real Life Scenarios


Case Study 10: 64610



The patient was brought to the operating room and kept in a supine position on the operating room table. After intravenous antibiotics were given, the patient was placed under general endotracheal anesthesia. At this point the right buccal area externally was prepped and draped in a sterile fashion. An entry point was designed approximately 2.5 cm lateral to the lateral canthus of the mouth and a trajectory was selected in the mid papillary line meeting a line tangentially from approximately 3.5 cm in front of the tragus. With this completed, the sterile needle was used and placed through the cheek tissue. A gloved finger was placed into the medial wall of the buccal mucosa to assure that this was not violated. The area of the medial process of the mandible 3 was palpated and #20 spinal needle was easily passed medial to the jaw. Upper fluoroscopic

guidance, the foramen ovale was identified. We did meet bony resistance despite lateral and AP views seeming to indicate that we were directly into the ovale. We continued and several small adjustments were necessary for the needle until the foramen was entered. This allowed easy entrance into the foramen. There was a jaw jerk as the foramen was entered.

Lateral and AP x-rays were performed to confirm that the correct level was identified, and when the stylette was removed we got return of clear cerebrospinal fluid. With this indication, the patient was brought to a completely upright position. The approximately 0.2 cc of anhydrous glycerol were injected. There was no evidence of bradycardia or other cardiac events from this. With this completed the stylette and needle were

removed. Pressure was held on the cheek. The cheek was then cleaned and a Band-Aid was placed.

At this point, with the patient maintaining an upright position, he was extubated and taken to the recovery room in stable condition having tolerated the procedure well. The patient will continue in an upright position for one hour postoperatively.


Case Study 11: 64620, 64620-59, 64620-59

PREOPERATIVE DIAGNOSIS: Intercostal neuralgia.

POSTOPERATIVE DIAGNOSIS: Intercostal neuralgia.

OPERATION: Radiofrequency denervation of the left 7th, 8th and 9th intercostals nerves.






HISTORY: The patient has had tingling 10/10 pain underneath the left breast to the mid-abdominal area aggravated by activity and contact to the area. She had an intercostal nerve block with steroid at the left 8th, 9th and 10th nerves with only several days of relief. Today her pain seems primary in the left 6th, 7th, 8th and 9th, although she had some left T4-5 thoracic dermatome.

Today, I performed radiofrequency denervation, after informing the patient of the risks of bleeding, infection, nerve injury, paralysis, increased pain, failure to relieve the pain permanently or temporarily, headaches and reaction to medications, numbness and weakness and pneumothorax. All questions were answered and options were explained. The patient’s n.p.o. status was confirmed.

PROCEDURE: In the prone position, the back was prepped and draped in the usual sterile fashion. Five cc of 2% lidocaine was used for local anesthesia using a 27-gauge needle. Under fluoroscopic guidance 100.5 mm 20-gauge Sluijter-Mehta needle was inserted inferior to the left 7th, 8th and 9th ribs.

No spinal blood was present. Then 90 seconds at 80 degrees cGy lesions was accomplished after 1.0 cc of 0.5% bupivacaine was given per level. The patient tolerated the procedure well.

The patient’s vital signs were stable. Propofol 140 mg was given in divided doses for sedation. I will see the patient in the office for follow-up. Thank you for this referral.


Case Study 12: 64622-50, 64623-50, 64623-50

Preoperative Diagnosis: Lumbar spondylosis without myelopathy.

Procedure: Lumbar facet rhizotomies L3-4, L4-5, L5-S1 bilateral.

Postoperative Diagnosis: Lumbar spondylosis without myelopathy.

Anesthesia: IV sedation.

Estimated blood loss: Minimal.

Replacement: Crystalloid.

Complications: None.

Procedure: Patient was positioned supine. IV sedation was established. The patient was then positioned prone. The lumbosacral area was prepped in the usual fashion. Under fluoroscopic guidance the target identified as the upper outer quadrant of the L5-S1 articulation on the right was localized. The skin was anesthetized and the rhizotomy needle was passed to the area. A lesion was created at 80 __ for 90 seconds. This procedure was then repeated for the contralateral L5-S1, the bilateral L4-5 and bilateral L3-4 levels. The patient having tolerated the procedure well was transported to the Recovery area in satisfactory condition.



Case Study for Epidurogram


An epidurogram is a diagnostic procedure. During the procedure, the provider injects contrast into the epidural space, under direct fluoroscopy to confirm localization of an injection. An epidurogram may be used to identify areas of scarring, bony narrowing, nerve and/or nerve root constriction, other compressive lesions, possible nerve inflammation, and the degree of fluid flow (or lack of) in the epidural space.

The completed procedure will result in a permanent radiological image of the epidural space. To report an epidurogram, code 72275 Epidurography,

radiological supervison and interpretation is assigned.


Frequently an epidurogram will be performed by an anesthesiologist with various procedures for pain management – typically nerve blocks and epidural injections. When billing for this procedure, bill as a type of service 04 (rather than 07 for anesthesia coding), and assign 72275 with the modifier –26 to indicate that it is a report for the professional component for the reading of the service. In addition, it is important to understand that 72006 Fluoroscopy would not be billed

separately as these procedures are considered bundled.

An epidurogram is only payable when it is performed, images are documented, and a formal radiologic report is issued. When the anesthesiologist is

documenting the procedure, it is suggested that a paragraph be included to state the epidurogram findings. A report that states: “Epidurogram completed without difficulty” does not qualify for reporting 72275.

In addition, 72275 includes fluoroscopic guidance and localization. Therefore, code 76005 Fluoroscopic guidance and localization of needle or catheter tip for

spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction should

not be reported in addition to code 72275.

When assigning 72275 appropriately, it may also be acceptable to assign a code for injection procedures to include 62280-62282, 62310-62319, 64479-64484, and 0027T, as stated in the notes located with the 72275 code description.

When reporting codes 62310-62319 (inherently unilateral procedures), assign once per level, per side, regardless of the number or type of injections performed per level, per site. It would not be appropriate to report the spinal injection code(s) for each injection performed at a particular level and side. If, however, both sides of the same spinal level are injected, then modifier –50 should be appended to the specific injection procedure code to indicate such. If injections


are performed at different spinal levels (e.g. C2 and C4), then the spinal injection codes are reported for each level of the spinal region involved.

An example of accurate assignment of an injection code with the epidurogram includes:

If epidurography is performed at the cervical and lumbar region, report codes 62310 with 72275 for the cervical injection and epidurography, and codes 62311 and 72275 for the lumbar injection and epidurography.


When justifying the epidurogram procedure, the report must include a description of the area injection, the substance(s) injected, and the dosage of the

substance(s). It will typically describe the flow of the contrast into the epidural space, any blockages that were seen and the flow around the nerve root.

Medical Necessity

An epidurogram must be reasonable and necessary to diagnose or treat a problem. Therefore, an epidurogram must have a diagnostic purpose, as

opposed to a needle localization purpose. The provider must justify the need for the epidurogram in his/her documentation and that information must be available upon request of the fiscal intermediary (FI).

If more than one epidural injection is needed to image a contiguous epidural space on the same day, typically 72275 may be reported one time only. For example, if L5-S1 is injection and demonstrates a blockage, and then another injection is performed at L4-5 to confirm the blockage, the second injection and image is considered to be part of the initial study rather than a separate


If, however, an epidurogram is performed at multiple separate spinal level, it may be reported once for each non-contiguous spinal regions examined – such as once for the cervical region and once for the lumbar region.

When reporting code 72275 on the same date as a therapeutic injection service – such as 64483 Injection anesthetic agent and/or steroid, transforminal epidural;

lumbar or sacral, single level the epidurogram must be medically justified.

Examples of the demonstration of medical necessity include:

• Clinical evidence suggesting that the patient may require an additional therapeutic injection (e.g. steroid) at more than one spinal level, an initial epidurogram may be considered reasonable and necessary. In this case, it may be needed to detect an epidural blockage that would require a therapeutic injection at two separate sites: one above and one below the blockage.


• A subsequent epidurogram (different date) may be necessary when a flow blockage or restriction is detected on the prior epidurogram, and the patient may require another therapeutic injection above and below the blockage – the epidurogram performed to determine whether the blockage has resolved.

However, if an initial epidurogram does not show any blockage, a subsequent epidurogram in the same body area would not be considered medically necessary.

CPT is a copyright of the American Medical Association (AMA) CPT Assistant 2000 January Article 1


V. 2005 CPT Coding Update

The CPT 2005 code book contains two new emerging technology CPT codes for percutaneous intradiscal annuloplasty. Medicare coverage and/or payment of these new codes will be published when the 2005 updates to the Medicare hospital outpatient prospective payment system and the Medicare physician fee schedule are published.

0062T Code added

Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level

 0063T Code added

Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to 0062T for primary procedure)


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