Coding

[spondy14]

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Has anyone heard that you can no longer code for fluoro with a transforaminal ESI, that in 2011 it is now bundled? What about interlam or SIJ?

 

[SSdoc33]

what?!?!?!?! you don't say.

 

[PMR 4 MSK]

Has anyone heard that you can no longer code for fluoro with a transforaminal ESI, that in 2011 it is now bundled? What about interlam or SIJ?

Yes to the first question.

2012 or 2013 for the second, most likely.

 

[onewithpain]

21st century edge (a consulting firm) sent out an email saying that The November 2010 issue of the AMA CPT Assistant states that fluoroscopic guidance is bundled with epidural codes including CPT codes 62310 - 62319. This leaves physician in a gray area. The AMA CPT book states one thing and the CPT Assistant states another. We look for the AMA CPT Assistance to issue a retraction on this matter; however some payers may jump at the chance to use this article as justification to no longer pay for fluoroscopic guidance. On the one hand it could be used to lower our reimbursement, and on the other it would keep anyone from legally billing that code if they didn't use fluoro.

 

[onewithpain]

The latest from 21st century edge; On January 5, 2011, the American Medical Association (AMA) issued a retraction of its statement in the November, 2010 CPT Assistant that fluoroscopic guidance is inclusive of epidural procedures.

The AMA retraction states:

“For certain spinal procedures, fluoroscopy is NOT considered inclusive of the procedure (e.g., 62267, 62270-62282, 62310-62319) and is indeed reportable, when performed.”

 

[bedrock]

so are you still coding for fluoro with your TFESI?

The first two weeks of 2011 I'm still coding for TFESI fluoro with all insurances other than medicare because of these discrepancies. Kinda like I still code for consults for all insurances other than medicare (and so does everyone else I know).
How is everyone else on the forum handling TFESI fluoro codes so far this year?

 

[onewithpain]

This is the latest on billing consults from my coders.

January 12, 2011



Good morning,


In an effort to keep you informed about which insurances are no longer accepting consultation codes, we are providing you with an updated list.


MEDICARE BASED
ATRIO MEDICARE
HEALTH NET MEDICARE ADVANTAGE
HUMANA GOLD CHOICE MEDICARE
MEDICARE
RAILROAD MEDICARE
REGENCE MEDICARE ADVANTAGE
SECURE HORIZONS
STERLING OPTIONS MEDICARE REPLACEMENT

OTHER INSURANCES
BCC PROGRAM
CARE OREGON MEDICAID
DOCS MEDICAID OHP (1/1/11)
HUMANA VETERANS
OMAP
REGENCE BC/BS (8/1/2010)
REGENCE FEDERAL

If any of above listed insurances are the patient's primary insurance you cannot bill with a consult code for office or hospital visits. Those codes are: (99241-99245 and 99251-99255). Please refer to the crosswalk attached for an alternate code.

 

[onewithpain]

And yes I do bill fluoro for all transforaminals, even medicare.

 

[bedrock]

And yes I do bill fluoro for all transforaminals, even medicare.

Is it legal to bill medicare for something they won't pay by their latest guidelines?

This is my second year of practice and I guess I still play things safe. Again that's why I ask how the more experienced players have approached these things over the years

 

[stim4u]

oops, I put this in another forum.

In protest we should ALL bill 77003 for every tfesi procedure. Let them come after all of us..... Any cowboys out there.

In reality, they(medicare) will simply lock out the 77003 code anyway, like they are starting to do now in my region.

Since 64483/4 was not reformulated like facets, and since there is controversy as to whether bundling is appropriate or not, I would continue to bill commercial insurances.

 

[PainConsultant]

Fluoroscopic guidance CPT code 77003 was bundled with transforaminal epidurals CPT codes 64479/64480 cervical and 64483/64484 lumbar by the AMA on January 1, 2011. At the annual CPT meeting, AMA representatives stated that if there is a 75% or higher correlation of two procedures being performed in the same case that they will be reviewing them for possible bundling. The AMA representative also stated that payers want one CPT code for the entire case.

Last year on January 1, 2010 new facets codes were created. This codes bundled facets with fluoroscopic guidance.

There was an error in the November issue of the AMA CPT Assistant that stated that interlaminar epidurals CPT codes 62310 cervical and 62311 lumbar were bundled with fluorscopic guiance code 77003. On January 5, 2011 the AMA issued a correction. Fluoroscopy is not bundled with interlaminar epidurals.

 

[TX PAIN DOC]

If they are bundling fluoro with Tf ESIs, has the reimbursement gone up for the corresponding CPT codes 64479 thru 64484? I wonder how much that reimbursement increase, if any, compares with billing 77003 seperately.

 

[PMR 4 MSK]

Is it legal to bill medicare for something they won't pay by their latest guidelines?

This is my second year of practice and I guess I still play things safe. Again that's why I ask how the more experienced players have approached these things over the years

Technically, no. Medicare guidelines require you to know the guidelines and keep up to date with them.

You can bill for something you know they don't pay for, such as PRP, provided you have the pt sign an ABN, and code it as such. However, if they claim a code is now "bundled" with another code, you cannot bill for it, even with an ABN.

During the initial stages of new coding, they will simply send the EOB with a comment that they are not paying for things such as fluoro with TFESI. After a while they often change it to read that you are "unbundling." Then after another while, they have the option of going after doctors who persist in "unbundling" procedure codes, and can even fine you for doing it. My guess is they have a threshold for doing that.

 

[MedZeppelin]

Sorry to change the procedure, but could I ask for some opinions...?

If I'm not mistaken, if I perform three lumbar injections for L3, L4 medial branch nerves and L5 dorsal ramus, I can bill for 2 levels (64493, 64494) for L4/5, and L5/S1 facet joints, or can I bill for three levels (64493, 64494, 64495) for the individual nerves themselves?

Thereafter, I can only perform RFA on the three nerves (L3,L4,L5), right? Is anyone performing 4 lesions per side to cover three joints, and if so is insurance covering this?

Thanks!

 

[bedrock]

The billing done differently for RF levels vs facet injections/MBB levels

RF is by nerve- you burn 3 nerves for 2 joints so bill for 3 nerves

facet injections/MBB are by joints- 2 facet injections= 2 joints or 3 MBB for two joints=2 joints

 

[MedZeppelin]

Thanks for the clarification! That sums it up very well!

Also, I believe that you are not reimbursed for more than 3 RF levels per session. Is this true?

Thanks

 

[PMR 4 MSK]

Thanks for the clarification! That sums it up very well!

Also, I believe that you are not reimbursed for more than 3 RF levels per session. Is this true?

Thanks

Depends on payer and state.

Guys by me (one in particular) are still doing bilateral 5-level RFAs +/- SI RF at the same time

 

[Pain_doc]

3 levels for mbbs or facets are reimbursed at one time. You can do as many nerve RF's as you want at one time.....but realize that reimbursement is "halved" for each successive nerve after the second nerve. That is, you get (hypothetically) paid $300 for the first nerve, $100 for the second, then its $50 for the third, $25 for the fourth, $12.50 for the next and so on. Not even covering the cost of the needle.

 

[lobelsteve]

3 levels for mbbs or facets are reimbursed at one time. You can do as many nerve RF's as you want at one time.....but realize that reimbursement is "halved" for each successive nerve after the second nerve. That is, you get (hypothetically) paid $300 for the first nerve, $100 for the second, then its $50 for the third, $25 for the fourth, $12.50 for the next and so on. Not even covering the cost of the needle.

I believe for the RF you get 100% of first level and 50% for each addl level.

 

[painstop]

So since RF is billed per number of nerves, is this discrepancy between what people are getting paid for second and third levels merely due to contract agreements with the providers....or is this simply a comparison of apples (CMS) to oranges (private insurers). I don't have a CPT coding book in front of me but I'm wondering who is right?

 

[Jcm800]

Depends on payer and state.

Guys by me (one in particular) are still doing bilateral 5-level RFAs +/- SI RF at the same time

same guy as before?

 

[Pain_doc]

Check your EOBs about the reimbursement. My billing service informed me of the payment discrepancy -- after I asked. The RF's get billed at full price, but medicare and commercial insurance reduce the amount after the second nerve (for lumbar/cervical rf where there is a first and second nerve code). I looked at some EOBs in the past and that as indeed how I was reimbursed.

 

[MedZeppelin]

Thanks for the tips..

My confusion about MBB coding stems from a billing specialist recently telling me that if I block 3 medial branch nerves (eg. L3,L4, L5DR), I should bill as three levels (64493,64494,64495). The justification was that the code is for facet joints and/or nerve levels??? Also,If I had a photo of the three needles down to the levels, that's all I need for proof?

That seems contrary to the anatomy...any thoughts????

 

[bedrock]

One would assume that since their job is billing, that a billing professional should always know more than their physicians about billing. Unfortunately that's not always the case. I've had to correct my biller several times over the past year, for things she should know better than me.

Ultimately the physician is still legally responsible for how their services are billed so you need to know for yourself and not simply trust billing people.

 

[PMR 4 MSK]

same guy as before?