77003 Vs. 77002 for the SI joint

[Ligament]

Originally Posted by Tenesma :

"but here is another 77003 issue

is an SI joint 77003 or 77002 --- initially i was coding 77002 but was told by several professional coders i should change to 77003 since it is para-spinal... Like a facet joint - kind of...

i have been charging 77003 ever since - but i still scratch my head..."
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This is a direct quote from 2007 AMA CPT book (all trademarks, copyrights, etc etc)

77003- 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

when in doubt, always go to the source!

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[lobelsteve]

77003 unless it is a hip joint, or you are having fun with shoulder or knee arthrograms (I would bill the fluoro but not the reading if I was playing in the knee or shoulder).

 

[Tenesma]

there are some pain guys who are doing all of their trigger points under fluoro - what do you guys think???

i think it makes sense if it is a very skinny old lady and you are injecting a muscle near the lungs.... for precautionary reasons

 

[Mister Mxyzptlk]

CT-guided TPIs can't be very far behind.

 

[lobelsteve]

there are some pain guys who are doing all of their trigger points under fluoro - what do you guys think???

i think it makes sense if it is a very skinny old lady and you are injecting a muscle near the lungs.... for precautionary reasons

Malpractice. Radiation ain't free. They are increasing the risk of cancer, defrauding insurance, and providing no legitmate care for these patients.

 

[Tenesma]

well fluoro is useful in my opinion if you are doing a very specific muscle blockade and you are using contrast... ie: psoas muscle or whatnot... but still, i agree it can get fishy...

 

[Ligament]

77003 unless it is a hip joint, or you are having fun with shoulder or knee arthrograms (I would bill the fluoro but not the reading if I was playing in the knee or shoulder).

the sympathetic and peripheral nerve blocks would also be 77002. Perc disc is also 77002 (strange, but true). Pretty much everything EXCEPT, epidurals (including blood patch and spinal tap), subarachnoid, facets (block or RF) and SI's would be 77002.
Of course there are those arthrogram codes, but I agree that I wouldn't be billing to read knee or shoulder 'grams. I personally don't feel qualified and it gets the radiologists all in a tizzy...
I only bill SI 'grams, and then only on the first SI injection. I've heard some people billing it repeatedly with every injection, but I don't know how they can justify the extra payment for this repeated diagnostic study to the utilization people.
Speaking of SI's, did you know that you CANNOT use the 27096 code unless you use fluro or do an arthrogram? Quoting AMA CPT 2007 again:
Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
If you do it blind, you are supposed to use the large joint code 20610, because 27096 is defined (and priced) with the extra work of using fluoro. I think that was another AMA coding article, but I forget.

Maybe we should harass the AMA to come up with a separate code for blind medial branches and blind epidurals?

 

[Tenesma]

can you explain how an SI gram would increase my revenue?

 

[Mister Mxyzptlk]

can you explain how an SI gram would increase my revenue?

You could dictate a formal diagnostic arthrogram report, 73542. I highly don't recommend it (unless you want to emulate the people who dictate a formal epidurography report and bill for it when they perform an ESI).

BCBSTX will not pay for diagnostic SI injection. Therapeutic SI injections are covered.

 

[Tenesma]

but if it is reimbursed will it financially make a big difference???

 

[Mister Mxyzptlk]

Medicare pays $104 either office or facility. If you bill it together with something else they will probably reduce it 50%.

The injection of contrast is bundled into a therapeutic injection (27096), which is $202 office and $65 facility.

If you try to unbundle using 73542 that could raise a flag because they would have a charge for a therapeutic and a diagnostic injection for the same needle.

CMS does profile us. I was sent a warning last year because my distribution of codes for initial H&P was skewed from my peer group. I tried to point out that I am supposed to be 09 and they compared me to something else. They would not tell me what specialty code they have down for. I also told them flat out that I will always be skewed because the bar graph they sent me of my so-called peers shows a lot of low-level codes (99201 & 99202) and I never do that cursory of an initial evaluation. My typical report is 2-3 pages. So if you hear I have been fined for my Medicare billing there you have it. I am not going to downcode my work to fit a bell curve.

Given the data mining they do I think 73542 would stand out like a sore thumb. The private payers might not notice, and if they do most likely you'd have to refund the money. Be aware that they are also profiling though, and people are getting bounced out.

 

[Ligament]

Medicare pays $104 either office or facility. If you bill it together with something else they will probably reduce it 50%.

The injection of contrast is bundled into a therapeutic injection (27096), which is $202 office and $65 facility.

If you try to unbundle using 73542 that could raise a flag because they would have a charge for a therapeutic and a diagnostic injection for the same needle.

I'm not sure what you're saying here... 73542 (SI arthrogram) is NOT bundled into 27096 (SI injection), per Medicare's CCI edits. I agree, if you injected contrast AND steroid, then no, you can't bill 27096 twice, it's only billed as one injection. However, you can still bill 73542 *IF* you do a formal report. You are NOT un-bundling. You also cannot bill an additional 77003- you replace 77003 on the bill with 73542, so you can make about $25 extra on the total fee- I can't say if this is a big difference for you, Tenesma.

Also, there is no multiple procedure discount on the xrays, only the injection codes. So if you were to also do a L-MBB, you could bill a separate fluoro (77003-59) for the lumbar region and get paid 100% for that AND 73542- as long as it was approved. You bill 64475 first, since it pays more, then get 50% on 27096. Of course, showing medical necessity for all this will probably take some doing...

On the other hand, epidurography (72275) *IS* bundled into ESI (62311) per CCI, so in this case you are un-bundling and this would be a "red flag".

No, this does not make any logical sense why one 'gram is bundled and another is not, but when has Medicare been logical?! For me, it's kinda like paying taxes- I follow the rules and pay what I have to, but make sure to take every deduction I legally can.

Of course, gorback has that crazy BCBSTX to deal with and they seem to make completely different rules...

 

[Mister Mxyzptlk]

Ligament, we don't disagree. What I was trying to say was that contrast is usually bundled into an SI joint injection, but if you want to get paid for the contrast injection you can do 73542. I should have written "unbundle" (with quotes) to indicate that its not true unbundling.

The separate report approach to getting paid for contrast injection, whether SI arthrogram or epidurogram, makes me uneasy.

The ESI and SI CPT codes are very commonly billed codes and I would expect insurance companies to notice if there is someone routinely tacking on separate reports and bills for contrast injection. OTOH, unless it's Medicare the worst that's likely to happen is a denial of the bill for the extra report.

I have seen people bill an epidurogram as "myelography without dural puncture". I can't seem to find a description of that technique anywhere. Talk about "building the bill"!

 

[Mister Mxyzptlk]

Ligament, we don't disagree. What I was trying to say was that contrast is usually bundled into an SI joint injection, but if you want to get paid for the contrast injection you can do 73542. I should have written "unbundle" (with quotes) to indicate that its not true unbundling.

The separate report appraoch to getting piad for contrast injection, whether SI arthrogram or epidurogram, makes me uneasy.

The ESI and SI CPT codes are very commonly billed codes and I would expect insurance companies to notice if there is someone routinely tacking on separate reports and bills for contrast injection. OTOH, unless it's Medicare the worst that's likely to happen is a denial of the bill for the extra report.

I have seen people bill an epidurogram as "myelography without dural puncture". I can't seem to find a description of that technique anywhere. Talk about "building the bill"!