There are some issues being confused here. Medicare, with some exceptions, does not decide the definition of a code. That is the AMA's million dollar baby. What we first need to do is translate procedures into accurate coding language to get paid for what you do- no more, no less.
So, in this case, the AMA has defined the code 77003 as "code-able" per region and the regions are cervical, thoracic, lumbar and sacral. See AMA's CPT Assistant Archives Sept 2002 and Dec 2005 (specific to L5 and S1) and other "clinical vignette" examples. I know a doctor that had this information copied to him by BCBS when he tried to bill fluoro per level, same region, and they asked for his notes.
Medicare LCDs determine under what circumstance a procedure will be covered. If your local Medicare carrier has made an LCD that they will not cover procedures in 2 separate regions on the same day because it's "not medically necessary", then they can do that. That is NOT the same thing as them taking money back because you "falsely" coded a service you provided, i.e. billed and were paid for two fluoros in one region.
Right now, there is no NCD limiting the number of regions treated at the same time. I know some local Medicare carriers will pay, and some won't, for treatment in 2 different regions on the same day *when medically necessary* (which is a completely separate flame war.
) Of course, you will probably have to use modifiers (e.g. 59) on the fluoro to get it paid and you will have to take the multiple procedure discount (50% on 2nd injection, but paid 100% on 2nd fluoro- you really have to weigh lower payment vs. patient satisfaction having to come x2). I have even seen one case where THREE fluoro regions were billed and paid by Medicare on one poor train wreck...
Hypothetically, if you were to do a bilateral L3 and L4 TFESI, you could only bill 77003 one time (NOT x4) because it is one region. (Maybe this doesn't happen in reality, but it's a good example for coding, if not for medicine.)
If you do a T11, T12 and L1 TFESI, you could bill 77003 twice, once for thoracic and once for lumbar.
If you do a bilateral L5 and S1 TFESI, you could bill 77003 twice, once for lumbar and once for sacral.
I was able to speak to Joanne Mehmert again about this question. She felt that the verbage from the AMA clearly supports billing 77003 x2 and that the practice was defensible if questioned (audited). HOWEVER, with an aggressive prosecutor, she did say that it might be harder to show evidence that you had to perform more work, since the 2 nerves are so close. A more clear-cut example that we discussed was a L4 TFESI with a sacro-iliac injection. She said she would feel completely comfortable billing 77003 x2 for that because it is more obvious. An even more foggy example we discussed: LS/S1 interlaminar w/ a sacro-iliac injection. Medically, these are totally different procedures, and I would see the extra work in performing the second fluoro. BUT since they both border on the sacral region, the "common man" (read "insurance weasel") will tend to say they are both sacral (I mean, they both have an "S") and therefore are one region. In this case, she would only bill ONE fluoro.
Of course you don't want to bill inaccurately and subject yourself to audit. But at the same time, not billing for services that you did because you're afraid to, is a good way to go out of business. With the Medicare cuts, it's getting harder these days for ethical doctors who don't want to be block jocks to make a buck.
If it were my practice, I would either purchase the AMA's coding resources and read them myself (about $300) or write and ask the AMA your questions (you have to be a member -$420- for this, but it is an awesome online service that I have used several times) and get the info straight from the horse's @&#- I mean mouth!
PS- ASIPP, ISIS and Decision Health all provide coding classes in pain management. Again, if it were my practice, I would attend the courses myself and/or have the person who reviews all my claims attend one of these classes. Or you could pay for someone who's certified to come to your office and train everyone-then you can have them tailor the class to your practice. Be sure to list any courses you pursue and who attends in your HIPAA folder as a compliance training.
