Section 20-2-II - REIMBURSEMENT FOR PAIN MANAGEMENT SERVICESA.Use of Fluoroscopy. , Fluoroscopic guidance, CPT codes 77002 and 77003, may be billed once per date of service. Use CPT code 77002, fluoroscopic guidance for needle placement with CPT code 64510, injection anesthetic agent; stellate ganglion (cervical sympathetic) , or CPT code 64520, injection anesthetic agent; lumbar or thoracic (paravertebral sympathetic). Use CPT code 77003, for fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (e.g., cervical epidural or sacroiliac joint), and including facet nerve neurolytic agent destruction.
All procedures performed fluoroscopically MUST have stored hard copy or digital images showing final needle placement in at least two (2) views (typically posterior/anterior and lateral or oblique) demonstrating final needle placement and depth AND disbursement of contrast (when not contraindicated). These images must be available upon request (with appropriate HIPAA compliance) by payers, or reimbursement may be denied.
Fluoroscopy will be reimbursed for the following codes: 27096, 62321, 62323, 64479-64484, 64490-64495, 64600-64681, 64633-64636.
B.Reimbursement for Injection/Destruction Procedures1. Facet injections and medial branch blocks are reimbursed at a maximum of three (3) total anatomic joint levels. Additional level or bilateral modifiers may be used to allow up to a maximum of two (2) additional service levels for facet or medial branch blocks in the cervical/thoracic (64491 and 64492) or lumbar (64494 and 64495) for a maximum of three (3) procedure levels reimbursed per treatment session or day. These procedures are unilateral by definition. Bilateral modifiers may be used when nerves are treated bilaterally. Reimbursement of the bilateral modifier is twenty five percent (25%) of the base amount for the second or contralateral side for procedures listed in the Pain Management section. 2. Nerve destructive procedures are reimbursed for a maximum of two (2) anatomical levels. 3. Reimbursement for injection/destruction procedure codes is made on the basis of joint levels, not nerves treated (e.g., destruction by neurolytic agent of the L4-L5 facets counts as one (1) level/nerve and should be billed as 64635 (first level/nerve)). There are two nerves supplying each joint but reimbursement is based upon joint(s) treated, not the nerves treated. This applies to CPT codes 64635, 64636 (lumbar), and 64633, 64634 (cervical/thoracic). These procedures are unilateral by definition. Bilateral modifiers may be used when nerves are treated bilaterally. Reimbursement is twenty five percent (25%) of the base amount for the second or contralateral side when the bilateral modifier is used for procedures listed in the Pain Management section. 4. A maximum of two (2) levels of transforaminal epidural steroid injections or one level bilaterally are reimbursable for a given date of service. This applies to codes 64479, 64480, 64483, and 64484.5. A maximum of one (1) interlaminar epidural steroid injection is reimbursable for a given date of service. This applies to codes 62320 and 62322.6. If a patient with bilateral pain receives only unilateral treatment on a given date of service, any similar procedures (same CPT codes) performed on the contralateral side within ninety (90) days of the initial procedure will be subject to reimbursement reductions related to modifiers for bilateral treatment on the same date of service. For example, if a person undergoes a right sided medial branch block(s) or neurotomy(ies) on a given date of service, any similar procedure(s) on the left side will be subject to the reductions in reimbursement related to use of the bilateral modifier if this treatment is provided within ninety (90) days of the date of service of the right sided procedures. This rule applies to professional and facility reimbursement.C.Multiple Procedure Reimbursement. Only one (1) type of pain management procedure is reimbursable on a given date of service, unless otherwise approved by the payer. This rule does not include multiple level injections or bilateral procedures of the same type, with appropriate modifiers. "Type" is defined as any procedure code involving an anatomically different structure (e.g., spinal nerve, facet joint, sacroiliac joint, trigger point, etc.). Joints and nerves in different anatomical regions (cervical/thoracic, lumbar/sacral) are considered to be different "types" and is limited to one (1) procedure per given day. Additional level or bilateral injections of a single procedure in the same area are not considered different "types," and for the purpose of this rule, are considered to be the same "type." However, the multiple level restrictions, as detailed herein, still apply. Diagnostic injections of more than one type in the same anatomic area on the same date of service are prohibited, and will not be reimbursed without prior authorization. Reimbursement of the multiple procedure modifier (51) is twenty-five percent (25%) of the base amount for the second or additional procedure for procedures listed in the Pain Management section.
D. Repeat epidural injections would typically occur two to four (2-4) weeks after the initial treatment, contingent upon some degree of continuing radiating pain. Repeat injections performed within ten (10) days of the previous epidural injection will not be reimbursed. E. Sacroiliac arthrography (CPT code 27096) assumes the use of a fluoroscope and is considered an integral part of the arthrography procedures(s). Therefore, no additional fee for the fluoroscopy (CPT code 77002) will be reimbursed. This code may only be used twice per twelve (12) month period.F. Epidurography (CPT code 72275) is not reimbursable under this Fee Schedule. G. CPT code 62324 includes needle placement, catheter infusion, and subsequent injections. Code 62324 should be used for multiple solutions injected by way of the same catheter, or multiple bolus injections during the initial procedure. The epidural needle or catheter placement is inherent to the procedure, and, therefore, no additional charge for needle or catheter placement is allowed. H. Pain management procedures or services which are included in this section of the Fee Schedule must be performed by a licensed physician holding either an M.D. or D.O. degree. Pain management procedures performed by any other person, such as a Certified Registered Nurse Anesthetist (CRNA), are not eligible for reimbursement.I. The following procedures must be performed fluoroscopically in order to qualify for reimbursement: 1. Facet injections (64490-64495)2. Sacroiliac (SI) injections (27096).3. Transforaminal epidural steroid injections (64479, 64480, 64483, 64484).4. Cervical translaminar/interlaminar epidural injections 623215. Cervical/thoracic discography (CPT codes 62291 injection cervical/thoracic disc) and radiology supervision and interpretation (CPT code 72285) will not be reimbursed.J. Any analgesia/sedation used in the performance of the procedures in this section is considered integral to the procedure, and will not be separately reimbursed. This rule applies whether or not the person administering the analgesia/sedation is the physician who is performing the pain management injection. Administration of analgesia/sedation by a different person from the physician performing the injection, including an RN, PA, CRNA, or MD/DO, does not allow for separate billing of analgesia/sedation. If a patient is unable to cooperate during routine needle placement, despite judicious use of sedation for anxiety, elective IPM interventional pain management) procedures should be terminated due to patient safety concerns. Sedating or anesthetizing a patient into a plane of deep sedation or anesthesia, rendering them unconversant or unable to experience or communicate unusual or excessive pain puts the patient at increased risk for elective IPM procedures. K. Detailed anatomical descriptions of the procedures performed must accompany the bill for service in order to qualify for reimbursement. These descriptions must include landmarks used in determining needle positioning, needles used (size, length), and the type and quantity of each drug injected. Unless there is a contraindication to contrast media (e.g., documented allergy) it is expected that the quantity of contrast injection AND a written description of the contrast spread pattern be included in the procedure report. Generic descriptions such as "the procedure was performed in the usual fashion," "the needle was placed on (next to, by, etc.) the nerve/joint/target," "the needle was placed in the correct anatomical location," or similar wording, which was templated or otherwise lacking an actual detailed anatomical description of needle placement or contrast pattern (where appropriate), is inadequate and cause for denial of payment. Templates for standard needle placement are acceptable, but any deviation from the usual technique must be explained in the procedure note. Contrast injections patterns should not be templated. Tolerance to the procedure, and side effects or lack thereof should be included in this documentation.L.Radiographic Codes in Pain Management.1. Fluoroscopic imaging is reported with codes 77002 and 77003.2. Codes 72020-72220 which apply to radiographic examination of the spine are not reimbursed when performed with the pain management procedures in this section or with fluoroscopy services. If fluoroscopy codes 77002 and 77003 are used, appropriate images must be stored to receive reimbursement for the fluoroscopy code AND the procedure code for which fluoroscopy was reportedly used. This includes pre and post contrast images (unless contraindicated by contrast allergy) and at least two (2) views, posteroanterior (PA) and a depth view (oblique or lateral).3. Fluoroscopic codes will be reimbursed for the following codes: 27096, 62321, 62323, 64479-64484, 64490-64495, 64600-64681, 64633-64636M. When a joint injection is performed at the end of a surgical procedure for pain control, reimbursement is allowed according to the Multiple Procedure rule. This rule applies to professional and facility reimbursement.N. Reimbursement of the bilateral modifier is twenty-five percent (25%) of the base amount for the second or contralateral side for procedures listed in the Pain Management section.