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Coding & Billing
Getting Paid for Pain Management Fluoroscopy
Lolita Jones
Publish Date: October 10, 2007   |  Tags:   Financial Management

Lolita-Jones, RHIA, CSS Good news if your facility hosts pain management cases. Many payers no longer bundle fluoroscopy along with spinal injections, meaning you might be able to collect an additional facility fee for fluoroscopy. The company that provides code-bundling software to private health plans, including many Blue Cross Blue Shield licensees, has discontinued the edits bundling fluoroscopy CPT code 76005 in with many spinal injection codes, creating the possibility of obtaining additional reimbursement for fluoroscopy. Here are six tips for knowing if and when you're eligible to collect for this service.

Review the affected codes
The change doesn't apply to all pain management fluoroscopy. Software manufacturer McKesson discontinued fluoroscopy bundling edits for the following spinal injection codes:

  • 62270 to 62273
  • 62280 to 62282
  • 62310 to 62319
  • 64470 to 64476
  • 64479 to 64484
  • 64622 to 64627
  • 027T

Even if your payers use McKesson software, it doesn't necessarily mean they'll let you bill fluoroscopy along with these codes. The company's software is customizable, meaning each carrier still makes the final determination. Health plans using McKesson's software can either implement the change now or develop their own coverage policy to preserve the bundling edit.

Contact your payers
Before you begin to separately report CPT 76005, find out which payers use McKesson software and review your contract with those private payers to determine if your facility is eligible for fluoroscopy reimbursement. Ask the insurer if it has discontinued the bundling edits or implemented a policy to continue bundling 76005.

Learn the ground rules
Two ground rules to keep in mind:

  • Mention "under fluoroscopic guidance." Fluoroscopic guidance is a necessary component of every procedure associated with CPT code sets 64470 to 64476, 64479 to 64484 and 64622 to 64627 (source: American Medical Association CPT Assistant newsletter, March 2000). So for the operative report to support billing these codes, the pain management specialist must indicate that he performed the injections under fluoroscopic guidance.
  • Indicate the spinal region. CPT 76005 should be reported per spinal region (such as cervical or lumbar) and not per level of the injection (source: AMA CPT Assistant newsletter, September 2002). So when billing CPT 76005, be sure the procedure report indicates the spinal region. The level comes into play when coding and billing each individual injection.

Getting Paid For Implants

Q Our ACL reconstructions and meniscal repairs can be quite costly, but our freestanding surgery center charges very little for the screws and arrows we use in these cases. Where can I obtain a list of approved prosthetic-device codes?

A You can check with your local Medicare carrier for such a list, but very few Medicare-approved prosthetic-device codes are allowable in an ASC. Most reimbursement success comes from the carve-out of implants/prosthetic devices in the insurance contracts. While you're negotiating, you should determine if the unspecified HCPCS supply code will be used or the generic 99070, as well as what revenue code will be used. Implants in excess of $100 are usually carved out to recoup cost, plus at least 10 percent to 20 percent for shipping and handling.

Q Do carriers really accept 99070 as a valid code that can be used in an ASC setting? We haven't used 99070 for such miscellaneous supplies as screws and plates because the body of the description it reads "provided by the physician." We've used L8699, but don't always get reimbursed, especially by Blue Cross Blue Shield.

A While the use of 99070 is carrier-specific, for many carriers it's an acceptable way of billing for reimbursement of miscellaneous supplies. Your contract language should specify this, along with the revenue code the carrier requires.

- Judie English

Perform a self-assessment
Even if you get the thumbs up from your payer, perform a self-assessment before you start billing CPT 76005. Let's review a real-life ASC pain management case report involving fluoroscopy. As with billing all CPT codes, matching the correct procedure codes to an airtight procedure report is the key to timely payment in full for fluoroscopy and spinal injections.

As we deconstruct the following procedure description, we'll find the support your coders will need to bill CPT 76005 in conjunction with the appropriate related injections. (In the interest of space, we won't include the pre-operative diagnosis and procedure indications here, but these sections of the operative report are pre-requisites to establishing the medical necessity of the injections described).

Identified T9 and T10 facet joint on left side and prepped the skin with Betadine solution at T8 to S1 level. Identified T9 and T10 facet joint on the left side under fluoroscopic imaging. Anesthetized skin with 0.25% Bupivacaine. Inserted 25-gauge needle under fluoroscopic view and engaged facet joint. Position of the needle confirmed through the fluoroscopic view and injected 20mg of Depo-Medrol with 0.5cc of 0.25% Bupivacaine slowly with increments of 0.5cc at a time. Repeated procedure at the T10-11 and T11-12 levels.

This description provides your facility the support to bill four CPTs. The description for code 64470-LT reads, "injection facet joint nerve, thoracic, single level - left side." Because the procedure requires fluoroscopic guidance and the report confirms that the clinician performed fluoroscopy on the thoracic region, you may bill CPT 76005 if your payer permits it. The clinician also performed injections at two other left-side thoracic levels, so you're eligible to claim CPT 64472-LT twice (injection facet joint nerve, thoracic, each additional level - left side).

Next, I did the facet joint on the left side of the L3-4, L4-5 and L5-S1 level, in view of MRI report involvement of the facet arthropathy at those levels. The patient tolerated the procedure well. She was transferred to the recovery room, observed for 30 minutes and discharged. Follow-up by phone.

Now we learn that the clinician also used fluoroscopic guidance in the lumbar region, performing injections at three different levels on the left side of the facet joint. This enables you to use CPT 64476-LT (injection facet joint nerve, lumbar, single level - left side) and double up on CPT 64476-LT (injection facet joint nerve, lumbar, each additional level - left side). Because these injections involved fluoroscopy at a different region, you can also report 76005 again (with modifier ?59).

To summarize, it's proper in this case to report eight CPTs to a payer permitting separate fluoroscopy claims: 64470-LT, 64472-LT, 64472-LT again, 64475-LT, 64476-LT, 64476-LT again, 76005 (for the thoracic fluoroscopy) and 76005-59 (for the lumbar fluoroscopy).

Be consistent
Medicare doesn't provide facilities payment for CPT 76005. But if you're able use it with other payers, you may still want to report CPT 76005 with modifier ?GY to Medicare. The modifier refers to an item or service Medicare statutorily excludes or one that doesn't meet the definition of a Medicare benefit. The advantage of reporting 76005-GY to Medicare for informational purposes is that it acknowledges Medicare doesn't cover the code while promoting consistency in your coding and documentation practices. This can help make doing op report assessments a little easier - not to mention keeping your coders in practice for matching CPT 76005 to its related codes.

Scrutinize your payers
When you bill 76005 with your affected payers, examine the explanation of benefits (EOB) statements you receive from them to verify you're getting separate fluoroscopy payments. If you're not, and you've taken the steps to ensure both your eligibility and the veracity of the accompanying procedure report, you should contest the non-payment.