Ganglion Impar

[paindoctor2014]

What cpt code? Had a lot of trouble with this one

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[lobelsteve]

Depends on insurance.

Sympathetic block or medium joint.

 

[Taus]

Depends on insurance.

Sympathetic block or medium joint.

I have been billing small joint plus fluoro code. I was guessing on the small vs medium… figured was close to a finger/toe joint size. They’ve been paid. I always do the impar and sacro-coccygial articulation in combo. I guess I could also bill “other peripheral nerve block” with 59 modifier. Mine have all been for benign chronic coccydynia.

I used to bill the sympathetic block code…. As impar technically is…. But had a few denials from blues and United.

 

[SSdoc33]

pro tip: if you work for a hospital system, bill the sympathetic code, b/c you will get paid higher RVUs. unless your billers/admin are really good, then won't catch on. in the end, then $$$ [aid for the procedure should be the driving factor, but I doesn't work that way in all systems....

 

[Agast]

pro tip: if you work for a hospital system, bill the sympathetic code, b/c you will get paid higher RVUs. unless your billers/admin are really good, then won't catch on. in the end, then $$$ [aid for the procedure should be the driving factor, but I doesn't work that way in all systems....

Which sympathetic code are you using?

 

[bedrock]

I have been billing small joint plus fluoro code. I was guessing on the small vs medium… figured was close to a finger/toe joint size. They’ve been paid. I always do the impar and sacro-coccygial articulation in combo. I guess I could also bill “other peripheral nerve block” with 59 modifier. Mine have all been for benign chronic coccydynia.

I used to bill the sympathetic block code…. As impar technically is…. But had a few denials from blues and United.

I bill three codes. medium joint 20605, other nerve block 64450 for coccygeal nerve, and 77003 for fluoro.

It’s BS they don’t pay for LSB, so I claw it back

 

[paindoctor2014]

My billing dept has been arguing 64520 vs 64999 (which never gets paid)

 

[geauxg8rs]

pro tip: if you work for a hospital system, bill the sympathetic code, b/c you will get paid higher RVUs. unless your billers/admin are really good, then won't catch on. in the end, then $$$ [aid for the procedure should be the driving factor, but I doesn't work that way in all systems....

Yes bill for the sympathetic block since that is what you did and you should get the RVus for that.

 

[Ducttape]

64520.

 

[clubdeac]

I just found out the billing dept has changed all my ganglion impars from a 64520 to a 64999 which is like 1 Rvu. Arghhh

 

[SSdoc33]

I just found out the billing dept has changed all my ganglion impars from a 64520 to a 64999 which is like 1 Rvu. Arghhh

SIS says that is what is "supposed" to be.

still stinks, tho

 

[Ferrismonk]

At least you get something from the impar. I end up getting zero if its 64999. They don't reimburse that at all in private practice.

 

[RoloTomassi]

I just found out the billing dept has changed all my ganglion impars from a 64520 to a 64999 which is like 1 Rvu. Arghhh

How many do you do that that would make any meaningful difference? I do like 1/yr.

 

[bedrock]

How many do you do that that would make any meaningful difference? I do like 1/yr.

This.

I bill three codes. medium joint 20605, other nerve block 64450 for coccygeal nerve, and 77003 for fluoro.

It’s BS they don’t pay for LSB, so I claw it back

 

[SSdoc33]

ill do maybe 20/year. somehow i got to be known as the tailbone guy. not happy about it

 

[MitchLevi]

Chronic coccydynia after fracture responds nicely to sacrococcygeal jt injxns. I put 1-2cc anteriorly (ganglion impar essentially), 1cc in the joint and 1cc posteriorly. Bill for small jt injxn. These work the vast majority of the time.

 

[SC Tian]

nice, sometimes it is technically difficult to get into the joint due to variabilities, i put half in the front as ganglion impair, half in the sacral hiatus to block S5 posteriorly, and bill a sympathetic and caudal, they always switched to 64999 and caudal, anyway, it works very well to me.

 

[MitchLevi]

nice, sometimes it is technically difficult to get into the joint due to variabilities, i put half in the front as ganglion impair, half in the sacral hiatus to block S5 posteriorly, and bill a sympathetic and caudal, they always switched to 64999 and caudal, anyway, it works very well to me.

Why are yall billing multiple procedures simultaneously?

 

[SC Tian]

Why are yall billing multiple procedures simultaneously?

i do ganglion impar first using contrast to confirm, pulled needle back to do caudal using contrast to confirm, would be happy to know your comments for this billing. my understanding also from my observation is when i block the anterior and posterior it works and lasts longer, i would see compared to ganglion impar alone before, i almost always see more than 0.5-1 year relief.

 

[SC Tian]

also before i made changes, I studied the anatomy of coccyx

 

[MitchLevi]

I've never billed for 2 separate procedures on the same day. Didn't think that was allowed. I've done 2 procedures simultaneously, but only billed for one.

 

[DODOCSS]

I've never billed for 2 separate procedures on the same day. Didn't think that was allowed. I've done 2 procedures simultaneously, but only billed for one.

SIJ/GTB?

 

[bedrock]

I've never billed for 2 separate procedures on the same day. Didn't think that was allowed. I've done 2 procedures simultaneously, but only billed for one.

You can definitely do that. Generally one or both are not spine procedures,

Billing a joint injection and a nerve block 64450 on the same day is very doable.

Billing a LESI and a fluoro guided troch bursa injection are doable.

Billing a CESI and a lumbar RFA is not.

 

[SC Tian]

Interesting, ppl in our group do facet and sij, got paid 100% time.

 

[MitchLevi]

Interesting, ppl in our group do facet and sij, got paid 100% time.

So a pt has buttock pain and you shoot them with 1oz #8 12g and call it a day?

 

[SC Tian]

So a pt has buttock pain and you shoot them with 1oz #8 12g and call it a day?

non-sense, my friend, we are discussing whether you can bill two separate procedures in one day to help us understand this better. there is no need to be out of mind.

 

[MitchLevi]

non-sense, my friend, we are discussing whether you can bill two separate procedures in one day to help us understand this better. there is no need to be out of mind.

Haha.

I've just never considered injecting two body parts with overlapping pain patterns and billing for both.

I didn't know you could do that.

 

[SC Tian]

What is even commo is facet injection for cyst rupturing coupling with a transforaminal epidural, I guess what keep our specialty independent, is assessing patient, do your exam, the reason both should be done, not like some surgeons, family physicians or CRNAs abusing procedures, you seem to be very experienced, there is no need to repeat this.
Have a good night!

 

[PinchandBurn]

You can definitely do that. Generally one or both are not spine procedures,

Billing a joint injection and a nerve block 64450 on the same day is very doable.

Billing a LESI and a fluoro guided troch bursa injection are doable.

Billing a CESI and a lumbar RFA is not.

Brilliant

 

[Ferrismonk]

What is even commo is facet injection for cyst rupturing coupling with a transforaminal epidural, I guess what keep our specialty independent, is assessing patient, do your exam, the reason both should be done, not like some surgeons, family physicians or CRNAs abusing procedures, you seem to be very experienced, there is no need to repeat this.
Have a good night!

My brain hurt trying to read this.

 

[Agast]

My brain hurt trying to read this.

Some doctors here speak English as a second language. I’m only fluent in one.

The gist of what he’s saying is that he thinks an experienced pain physician can be trusted to combine procedures selectively, whereas others may just be padding the bill.

I do a lot of lumbar epidural + greater trochanter bursa injections, or cervical ESI with trapezius trigger point injections. If you don’t combine some of these procedures, patients erroneously think their epidurals did nothing.

 

[bedrock]

Brilliant

I do a lot of LESI plus troch bursa. More accurate than blind, you regain the flouro code they stole from us…and you can bill the 20610 + 77002 ( with a 59 modifier for both)

 

[SC Tian]

My brain hurt trying to read this.

Sorry, i hurt your brain, i was talking to my friend mitchlevi, maybe knowing that context can minimize the pain

 

[Dr. Ice]

The epidural is not meant to “fix” everything. Do the procedure, ask them to schedule a follow up if it still hurts and see what else to do. What’s the point of a shot gun approach to treatment? Epidural + tpi, or epidural + troch bursa injection? Why? Never done any of that in 14 years

 

[Greenbayslacker]

I do a lot of lumbar epidural + greater trochanter bursa injections, or cervical ESI with trapezius trigger point injections. If you don’t combine some of these procedures, patients erroneously think their epidurals did nothing.

I've been very clearly told by our billing dept that only one injection will be reimbursed per visit.

 

[Agast]

I've been very clearly told by our billing dept that only one injection will be reimbursed per visit.

I get paid 1/2 for the lesser procedure

 

[SC Tian]

i am in the process of reviewing both professional and facility billing of 2022, the second procedure is definitely paid, but only 50%. I do two separate procedures very rarely in the same visit, that is a compromised way be able to to bring this patient to our ASC, i just have no other options.

 

[Tboned]

Some doctors here speak English as a second language. I’m only fluent in one.

The gist of what he’s saying is that he thinks an experienced pain physician can be trusted to combine procedures selectively, whereas others may just be padding the bill.

I do a lot of lumbar epidural + greater trochanter bursa injections, or cervical ESI with trapezius trigger point injections. If you don’t combine some of these procedures, patients erroneously think their epidurals did nothi

I get paid 1/2 for the lesser procedure

Maybe your epidural did in fact do nothing or maybe it was the other injection? Who knows? I think doing those procedures together just muddies the water.

 

[bedrock]

i am in the process of reviewing both professional and facility billing of 2022, the second procedure is definitely paid, but only 50%. I do two separate procedures very rarely in the same visit, that is a compromised way be able to to bring this patient to our ASC, i just have no other options.

Yes. It is definitely important for everyone to know that the second procedure only pays 50% of its usual value if performed in the same day.

This is why I generally only do this with a procedure for which I can use a 77002 fluoro code. If you bill for the second procedure…and also for a fluoro code then it is still worth it because you get to bill two extra codes for one extra procedure.

 

[Baron Samedi]

-51 modifier, multiple procedures at same visit.

 

[DODOCSS]

-51 modifier, multiple procedures at same visit.

actually 50

 

[bedrock]

No, the best modifier is 59 because it denotes a clearly distinct procedure on a clearly different body part, compared to the primary procedure.

 

[pmrmd]

Yes. It is definitely important for everyone to know that the second procedure only pays 50% of its usual value if performed in the same day.

This is why I generally only do this with a procedure for which I can use a 77002 fluoro code. If you bill for the second procedure…and also for a fluoro code then it is still worth it because you get to bill two extra codes for one extra procedure.

Hmmmm. I thought we could bill only one fluoro code for the day for the procedures. Maybe that is just Medicare.

 

[bedrock]

Hmmmm. I thought we could bill only one fluoro code for the day for the procedures. Maybe that is just Medicare.

You actually don’t get to bill a separate fluoro code anymore with 95% of spine procedures.

That’s why it is so nice to bill a separate 77002 code which is a code for non spine flouro guidance + another procedure. If it’s a different procedure then the billing for that procedure are what apply to a particular patient.

I do a lot of Medicare ESI + troch bursa and I’m always paid.
(ESI code, 20610-59 77002-59, steroid code)

 

[SSdoc33]

I do a lot of LESI plus troch bursa. More accurate than blind, you regain the flouro code they stole from us…and you can bill the 20610 + 77002 ( with a 59 modifier for both)

This is exactly what i do.

Its funny how some docs end up injecting and billing the same way. Nobody taught either of us to do this im guessing.

 

[SSdoc33]

I've been very clearly told by our billing dept that only one injection will be reimbursed per visit.

They are wrong.

One 'spine' injection maybe

 

[bedrock]

This is exactly what i do.

Its funny how some docs end up injecting and billing the same way. Nobody taught either of us to do this im guessing.

Yep exactly. I just figured it out along the way. No one taught me anything about this.

 

[Ducttape]

You can definitely do that. Generally one or both are not spine procedures,

Billing a joint injection and a nerve block 64450 on the same day is very doable.

Billing a LESI and a fluoro guided troch bursa injection are doable.

Billing a CESI and a lumbar RFA is not.

but not for Medicare patients, unless you are making a special exception.

You actually don’t get to bill a separate fluoro code anymore with 95% of spine procedures.

That’s why it is so nice to bill a separate 77002 code which is a code for non spine flouro guidance + another procedure. If it’s a different procedure then the billing for that procedure are what apply to a particular patient.

I do a lot of Medicare ESI + troch bursa and I’m always paid.
(ESI code, 20610-59 77002-59, steroid code)

for new people - there is a huge misnomer that "i always get paid by Medicare" means that everything is approved.

Medicare will pay readily at time of procedure. - but may do retroactive chart audits way down the line, will claim that the doctor is defrauding Medicare and request pay back for procedures that were not done the way that they want.

1. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks, trigger point injections etc.) during the same session as ESIs, with the exception of a facet synovial cyst and ESI performed in the same session.

LCD - Epidural Steroid Injections for Pain Management (L39054)

Use this page to view details for the Local Coverage Determination for Epidural Steroid Injections for Pain Management.

www.cms.gov

and

1. It is not routinely necessary for multiple blocks (e.g., epidural injections, sympathetic blocks, trigger point injections, etc.) to be provided to a patient on the same day as facet joint procedures. Multiple blocks on the same day could lead to improper or lack of diagnosis. If performed, the medical necessity of each injection (at the same or a different level) must be clearly documented in the medical record. For example, the performance of both paravertebral facet joint procedures(s) and a transforaminal epidural injection (TFESI) at the same or close spinal level at the same encounter would not be expected unless a synovial cyst is compressing the nerve root. In this situation, TFESI may provide relief for the radicular pain, while the facet cyst rupture allows nerve root decompression. Frequent reporting of multiple blocks on the same day may trigger a focused medical review.
   

LCD - Facet Joint Interventions for Pain Management (L38803)

Use this page to view details for the Local Coverage Determination for Facet Joint Interventions for Pain Management.

www.cms.gov

 

[buddababa]

actually 50

no 50 is bilateral

 

[bedrock]

It is not routinely necessary for multiple blocks (e.g., epidural injections, sympathetic blocks, trigger point injections, etc.) to be provided to a patient on the same day as facet joint procedures. Multiple blocks on the same day could lead to improper or lack of diagnosis. If performed, the medical necessity of each injection (at the same or a different level)

If I do 6 medicare ESI with a troch bursa injection, out of 80 medicare injections that I do in a month, it is not a routine injection as I'm doing this on less than 10% of the medicare ESI each month.

Besides, most of these patients have had previous blind bursa injections with less than ideal relief, which i document, and so I then have justification to do ESI with bursa injection.

Medicare has never had a issue with me doing this over a dozen years in three states. Always been paid.

I don't spend my time worrying about stupid "guidelines" made by bureaucrats who don't know anything about my clinical field.