August 4, 2008

Coding for Pain Management Services
For The Record
Vol. 20 No. 16 P. 34

There are many ways to treat pain, including injections and destruction by a neurolytic agent.

Injections
Injections are commonly used to treat spinal pain. Conditions that warrant such treatment can include spinal radiculopathy, spinal stenosis, degenerative disc disease, herniated intravertebral discs, and failed back syndrome. To determine which series of CPT codes to use, keep the following questions in mind:

• What is the approach — epidural, transforaminal, or facet?

• What is being injected — anesthetic, steroid, contrast, or a neurolytic agent?

• What regions are being treated — cervical, thoracic, lumbar, or sacral?

• How many levels are being treated?

• Is it a unilateral or a bilateral injection?

Injection procedures are considered unilateral and should be reported once per level per side (CPT Assistant, November 1999). Multiple injections at the same level on the same side are only reported once.

Epidural injections are administered between the vertebral segments into the epidural space (the fluid-filled sac that surrounds the spinal cord). The CPT code assignments for a single epidural injection are 62310, cervical/thoracic region; or 62311, lumbar/sacral (caudal) region.

The CPT code assignments for epidural injections by infusion or bolus are 62318, cervical/thoracic regions; or 62319, lumbar/sacral (caudal) regions. The catheter placement for infusion or bolus is included in these procedures and should not be reported separately.

Transforaminal injections are administered by way of the intravertebral foramen located on each side of the vertebra where the nerve root exits the spinal column. The CPT code assignments for transforaminal injections of an anesthetic agent and/or steroid are as follows:

• 64479, single-level injection cervical/thoracic region;

• 64480, each additional level cervical/thoracic region;

• 64483, single-level injection lumbar/sacral region; and

• 64484, each additional level lumbar/sacral region.

An intravertebral facet joint or nerve block is administered by way of the intravertebral facet. Each vertebra has four facets supporting the bone in the vertebral column. Injections are performed to block pain signals from the symptomatic facet joint and associated nerves to the brain. The CPT code assignments for facet injections using an anesthetic agent and/or steroid are as follows:

• 64470, single-level cervical/thoracic region;

• 64472, each additional level cervical/thoracic region;

• 64475, single-level facet joint injection lumbar/sacral region; and

• 64476, each additional level lumbar/sacral region

Trigger Point Injections
A trigger point is a painful area of soft tissue or surrounding muscle. Anesthetic and/or steroid is injected into the area to relieve pain and may incorporate several injections into the same area. Assign code 20552 for a trigger point injection of one or two muscles and 20553 for injections of three or more muscles. Use only one code per session based on the number of muscles injected, not the number of injections given. Do not report codes 20552 and 20553 together.

Sacroiliac Joint Injections
A sacroiliac joint injection is used to treat pain associated with sacroiliitis. These services are reported with HCPCS level two codes for hospitals and ambulatory surgical centers under Medicare reporting guidelines. If the injection is therapeutic with the administration of a steroid or anesthetic, the appropriate code assignment is G0260 for provision of anesthetic, steroid, and/or other therapeutic agent, with or without arthrography. If reporting a diagnostic arthrography service, assign code G0259 and 73542 for arthrography.

Destruction by Neurolytic Agent
Radiofrequency (RF) ablation procedures are reported with the appropriate destruction codes. Note that the term neurolytic agent includes chemical, thermal, electrical, or RF methods. CPT assignment for paravertebral facet RF ablations are the following:

• 64626, single level of cervical /thoracic region;

• 64627, each additional level of cervical /thoracic region;

• 64622, single level of lumbar/sacral region; and

• 64623, each additional level of lumbar/sacral region.

Trigeminal ablations, or rhizotomy, is performed to treat trigeminal neuralgia or tic douloureux, an intensely painful condition of the face emanating from the fifth cranial nerve. The following codes are assigned for destruction by neurolytic agent:

• 64600, Supraorbital, infraorbital mental, or inferior alveolar;

• 64605, Second and third division at the foramen ovale; and

• 64610, Second and third division at the foramen ovale with radiologic monitoring.

Coding and sequencing for pain management services are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.