Billing for new CPT codes

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callmeanesthesia

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How are you billing for the new CPT codes? I can’t find any publications of LCD or NCD to provide guidance on medical necessity requirements. I have 2 sitting in my queue that need to be billed but I don’t know what I need to document. Not sure if it will be requiring one diagnostic block? Two? None?
Since there are no requirements published does that mean anything goes as long as it’s done correctly according to the CPT description?
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callmeanesthesia said:
How are you billing for the new CPT codes?.......Not sure if it will be requiring one diagnostic block? Two? None?
Click to expand...

The number of MBB required is based upon your carrier, not which CPT code your use. For instance, our LCD requires two diagnostic blocks prior to RFA.

In regard to CPT changes:

Attached is a copy of the changes and new procedures for 2020.

The biggest changes are as follows.

Injection of Anesthetic Agent (Nerve Block) Diagnostic or Therapeutic

64400-64455, 64461,64462,64463,64479,64480,64483,64484,64490-64495 are unilateral procedures.

For bilateral procedures, report 64400,64405,64408,64415,64416,64417,64418,64420,64425-64455,64461,64463,64479,64483,64490,64493 with modifier 50.

Report the add-on codes 64421,64462,64480,64484,64491,64492,64494,64495 x 2 units, when performed bilaterally.

DO NOT report with modifier -50

To report injection of anesthetic agent and/or steroid to the facial nerve use the unlisted code of 64999.

To report injection of anesthetic agent, and/or steroid to the phrenic nerve, cervical plexus use the unlisted code of 64999.

64451 is a new code and will be used to report injection, anesthetic agent, nerves innervating the sacroiliac joint with image guidance (i.e. fluoroscopy or computed tomography). Do not report 64451 in conjunction with the 64493, 64494,64495,77002, 77003, 77012,95873,95874. 76999 is to be used for ultrasound guidance

64454 – genicular nerve branches, including imaging guidance when performed – (64454 requires injecting all of the following genicular nerve branches: superolateral, superomedial, and inferomedical. If all 3 of these genicular nerve branches are not injected, report 64454 with modifier -52

Billing/Authorization example:

Lumbar TFESI – 3 Levels
64483 -50 x 1 unit
64484 x 4 units (cover’s bilaterally level 2, and 3)

MBB
Example:
64493- 50 x 1 unit
64494 x 2 units (no modifier)
64495 x 2 units (no modifier)

RFA
64635 – 50 x 1 unit
64636 - x 4 units (cover’s bilaterally 2 levels)

Cheers
 

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Umm..who does 3 level transforaminal injections?
 
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MBB
Example:
64493- 50 x 1 unit
64494 x 2 units (no modifier)
64495 x 2 units (no modifier)

This is how we’d bill a 3 level bil lmbb now? Not 93-50, 94-50, 95-50? Is that correct?
 
NOSfan said:
The number of MBB required is based upon your carrier, not which CPT code your use. For instance, our LCD requires two diagnostic blocks prior to RFA.

In regard to CPT changes:

Attached is a copy of the changes and new procedures for 2020.

The biggest changes are as follows.

Injection of Anesthetic Agent (Nerve Block) Diagnostic or Therapeutic

64400-64455, 64461,64462,64463,64479,64480,64483,64484,64490-64495 are unilateral procedures.

For bilateral procedures, report 64400,64405,64408,64415,64416,64417,64418,64420,64425-64455,64461,64463,64479,64483,64490,64493 with modifier 50.

Report the add-on codes 64421,64462,64480,64484,64491,64492,64494,64495 x 2 units, when performed bilaterally.

DO NOT report with modifier -50

To report injection of anesthetic agent and/or steroid to the facial nerve use the unlisted code of 64999.

To report injection of anesthetic agent, and/or steroid to the phrenic nerve, cervical plexus use the unlisted code of 64999.

64451 is a new code and will be used to report injection, anesthetic agent, nerves innervating the sacroiliac joint with image guidance (i.e. fluoroscopy or computed tomography). Do not report 64451 in conjunction with the 64493, 64494,64495,77002, 77003, 77012,95873,95874. 76999 is to be used for ultrasound guidance

64454 – genicular nerve branches, including imaging guidance when performed – (64454 requires injecting all of the following genicular nerve branches: superolateral, superomedial, and inferomedical. If all 3 of these genicular nerve branches are not injected, report 64454 with modifier -52

Billing/Authorization example:

Lumbar TFESI – 3 Levels
64483 -50 x 1 unit
64484 x 4 units (cover’s bilaterally level 2, and 3)

MBB
Example:
64493- 50 x 1 unit
64494 x 2 units (no modifier)
64495 x 2 units (no modifier)

RFA
64635 – 50 x 1 unit
64636 - x 4 units (cover’s bilaterally 2 levels)

Cheers
Click to expand...
Thank you. I was not aware of the changes to 50 modifier for add on level codes.
 
Thank you for the updated CPT definitions. I will have to go back and change a bunch for the past 2 weeks... Do these only apply to Medicare at this point or are the changes typically adopted across the board for commercial payors as well?

I was wondering specifically about the medical necessity requirements for genicular and SI joint RFA. These have not been added to an LCD as far as I can find. If I do and bill for a genicular ablation after one or no diagnostic block, and 2 weeks later they publish requirements for 2 blocks like the lumbar, am I in the clear?
 
Last edited:
Ducttape said:
this was common practice about 7 years ago.

add bilat SI injection and possibly throw in a FJI or two, and you get "the works".
Click to expand...
How did these docs get all these simultaneous treatments authorized? Or were they all Medicare patients?
 
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paindoc007 said:
MBB
Example:
64493- 50 x 1 unit
64494 x 2 units (no modifier)
64495 x 2 units (no modifier)

This is how we’d bill a 3 level bil lmbb now? Not 93-50, 94-50, 95-50? Is that correct?
Click to expand...
Yes I’d like to clarification on this as well. So you use the-50 modifier on the first level and all subsequent levels you add 2 units instead of the-50?

Seems like our reimbursement will go up then! Is this correct?
 
clubdeac said:
Yes I’d like to clarification on this as well. So you use the-50 modifier on the first level and all subsequent levels you add 2 units instead of the-50?

Seems like our reimbursement will go up then! Is this correct?
Click to expand...

With modifier 50, you get 50% reduction on opposite side. You also get 50% on 2nd unit when billing x 2 units. How does it increase reimbursement?
 
paindoc007 said:
mine would go up since wrvu would increase. I get 200% for 64494x2. 150% for 50 mod
Click to expand...
exactly! actually we were even worse off where I am. We were getting paid $0 for the -50 modifier. So this is a huge help
 
Sorry for the confusion. What i really meant was doing three level rfa bilaterally in one setting. I separate left and right in different sessions unless two or less levels due to insurance reason
 
paindoc007 said:
MBB
Example:
64493- 50 x 1 unit
64494 x 2 units (no modifier)
64495 x 2 units (no modifier)

This is how we’d bill a 3 level bil lmbb now? Not 93-50, 94-50, 95-50? Is that correct?
Click to expand...
While it is a subtle difference, I was told by my billers the correct way to bill would be:
64493 - 50
64494 - RT
64494 - LT
64495 - RT
64495 - LT
I was told that without the RT and LT modifiers we will be much less likely to be reimbursed for billing the add-on code x2. It seems pretty ridiculous to me.
 
No_Pain_No_Gain said:
While it is a subtle difference, I was told by my billers the correct way to bill would be:
64493 - 50
64494 - RT
64494 - LT
64495 - RT
64495 - LT
I was told that without the RT and LT modifiers we will be much less likely to be reimbursed for billing the add-on code x2. It seems pretty ridiculous to me.
Click to expand...
Damn this is going to be a lot more clicking for me....ughhh
 
No_Pain_No_Gain said:
While it is a subtle difference, I was told by my billers the correct way to bill would be:
64493 - 50
64494 - RT
64494 - LT
64495 - RT
64495 - LT
I was told that without the RT and LT modifiers we will be much less likely to be reimbursed for billing the add-on code x2. It seems pretty ridiculous to me.
Click to expand...

One should utilize laterality whenever possible......Even for ICD-10
 
NOSfan said:
The number of MBB required is based upon your carrier, not which CPT code your use. For instance, our LCD requires two diagnostic blocks prior to RFA.

In regard to CPT changes:

Attached is a copy of the changes and new procedures for 2020.

The biggest changes are as follows.

Injection of Anesthetic Agent (Nerve Block) Diagnostic or Therapeutic

64400-64455, 64461,64462,64463,64479,64480,64483,64484,64490-64495 are unilateral procedures.

For bilateral procedures, report 64400,64405,64408,64415,64416,64417,64418,64420,64425-64455,64461,64463,64479,64483,64490,64493 with modifier 50.

Report the add-on codes 64421,64462,64480,64484,64491,64492,64494,64495 x 2 units, when performed bilaterally.

DO NOT report with modifier -50

To report injection of anesthetic agent and/or steroid to the facial nerve use the unlisted code of 64999.

To report injection of anesthetic agent, and/or steroid to the phrenic nerve, cervical plexus use the unlisted code of 64999.

64451 is a new code and will be used to report injection, anesthetic agent, nerves innervating the sacroiliac joint with image guidance (i.e. fluoroscopy or computed tomography). Do not report 64451 in conjunction with the 64493, 64494,64495,77002, 77003, 77012,95873,95874. 76999 is to be used for ultrasound guidance

64454 – genicular nerve branches, including imaging guidance when performed – (64454 requires injecting all of the following genicular nerve branches: superolateral, superomedial, and inferomedical. If all 3 of these genicular nerve branches are not injected, report 64454 with modifier -52

Billing/Authorization example:

Lumbar TFESI – 3 Levels
64483 -50 x 1 unit
64484 x 4 units (cover’s bilaterally level 2, and 3)

MBB
Example:
64493- 50 x 1 unit
64494 x 2 units (no modifier)
64495 x 2 units (no modifier)

RFA
64635 – 50 x 1 unit
64636 - x 4 units (cover’s bilaterally 2 levels)

Cheers
Click to expand...
what book is that from?
 
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