Pain management services have been particularly hard hit by the new ASC payment system. Such commonly reported pain procedures as epidural and facet joint injections have seen payment reductions of about 20 percent for 2008, according to the American Society of Interventional Pain Physicians, which predicts up to a 40 percent reduction in reimbursement for common pain procedures by the time the new payment rates are fully implemented in 2011.

Vigilant and appropriate coding will become even more valuable to ensure that facilities specializing in pain management are collecting all the reimbursement they deserve. Test your skills now with this pain management coding self-quiz.

1. The physician performs bilateral cervical median descending branch nerve neurolysis via cryoablation at C4/C5, C5/C6 and C6/C7. How should you report this?
a. 64626 x 3
b. 62626, 62627 x 2
c. 62626-50, 62627-50 x 2
d. 64626 x 2, 64627 x 4

Correct answer: d. When reporting destructive nerve procedures, begin by counting the number of levels the physician treats. Note that the physician targets these injections at the space between vertebrae, not at the vertebrae themselves. Therefore, if the physician documents, for example, "Facet joint injection at C4/C5," this represents a single "level."

In this case, you'll report the initial level using 64626 (Destruction by neurolytic agent, paravertebral face joint nerve; cervical or thoracic, single level), and each additional level beyond the first using +64627 (... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]).

Medicare payors specify, "more than three levels of facet joint blocks to a patient on the same day is not considered medically necessary." If your specialist plans to treat more than three spinal levels, you may wish to seek pre-authorization, as Medicare is likely to reject the claim.

Because the facet joints are on either side of the vertebrae, physicians often — as in this case — perform procedures bilaterally. In an office setting, you'd append modifier 50 (Bilateral procedure) to the appropriate code(s) to describe procedures at a single level on both the left and right. But this method isn't appropriate in an ASC.

Although modifier 50 is on the list of modifiers approved for outpatient use, some payors (including Medicare) direct ASCs not to report modifier 50 and instead instruct you to report a bilateral procedure using two units of the applicable CPT code.

Medicare guidelines instruct, "bilateral procedures should be reported as a single unit on two separate lines or with ???2' in the ???units' field on one line, in order for both procedures to be paid."

"Use of the 50 modifier is not prohibited," CMS cautions, but "the modifier will not be recognized for payment purposes and may result in incorrect payment to ASCs."

In this case, therefore, you'd report 64626 x 2 for the bilateral procedure at the first level (C4/C5), as well as 64627 twice for the bilateral procedure at C5/C6 and 64627 twice more for the bilateral procedures at C6/C7 (for a total of 64627 x 4).

2. Using fluoroscopic guidance for needle placement, the physician targets the median nerve at T1/T2 for anesthetic injection. He administers two injections from the left, and repeats the exact sequence at T2/T3. How would you code this procedure?
a. 64470, 64472, 77003
b. 64470 x 2, 64472 x 2, 77003
c. 64470, 64472
d. 64626 x 2, 64627 x 2

Correct answer: c. Once again, you should begin by counting the number of levels the physician treats. Because the physician injected an anesthetic, you'd report 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) for the initial level and +64472 (???cervical or thoracic, each additional level [list separately in addition to code for primary procedure]) for the second level (although similar, 64626 and 64627 describe injections of neurolytic agents).

Carriers bundle multiple injections at the same spinal level. A typical Medicare local coverage decision, for example, states, "[a facet joint injection] is considered a single procedure whether or not it is performed as a single injection (intra-articular route) or more peripherally and blocking the articular nerves with two injections."

Note that this doesn't include bilateral injections, which occur on opposite sides of the same spinal level, but rather only multiple injections on the same side of the same spinal level.

For example, a physician must administer two injections to block the median branch nerve inside the joint because one branch of the nerve sits at the top of the facet joint and a second branch sits at the bottom. Although this requires two separate injections, it counts only as one level and, therefore, only one billable code unit.

In our scenario, you'd report 64470 (for the initial level T1/T2) and 64472 (for the second level T2/T3).

While CMS has loosened restrictions on billing "ancillary services" in the ASC, the agency assigns fluoroscopy code 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) an "N1" payment indicator. This means fluoroscopic guidance is a "packaged service/item," for which no separate payment is made.

3. The pain specialist blocks the brachial plexus using catheter infusion. Which code(s) should you select?
a. 64415
b. 64416
c. 64415, 64416
d. 64449

Correct answer: b. Nerve blocks can occur by single injection or continuous infusion by catheter. In this case, you should choose 64416 (Injection, anesthetic agent; brachial plexus, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration), which CPT lists immediately after the corresponding single injection code 64415 (Injection, anesthetic agent; brachial plexus, single). Do not report a single injection (64415) and continuous infusion (64416) for the same session.

In addition, all continuous infusion codes — 64416 (brachial plexus), 64446 and 64448 (femoral nerve), 64449 (lumbar plexus) and 64450 (other peripheral nerve or branch) — include both catheter placement and daily management for administering the anesthetic. Therefore, don't code separately for these services.

4. To treat low-back pain, the pain specialist provides one injection each to three trigger points in the multifidus muscle to the left of the L5 spinous process. How would you claim this?
a. 20552
b. 20552, 20552-59 x 2
c. 20553
d. 20553, 20553-59 x 2

Correct answer: a. For trigger point injections, you must count the number of muscles treated, not the number of injections given. If your specialist treats the pain with multiple trigger point injections but focuses on just one muscle (here, the multifidus), 20552 (Injection[s]; single or multiple trigger points[s], one or two muscle[s]) is appropriate.

You should report 20553 (... single or multiple trigger point[s], three or more muscles) if the physician treats three or more muscles. For example, your pain specialist targets three trigger points — the right trapezius, the right deltoid and the right levator scapulae muscles — for a patient with neck and right shoulder-joint pain. He administers injections to each muscle. Here, you should report one unit of 20553.

Never report more than one unit of 20552 or 20553 per session. Because the code descriptors refer to "single or multiple injections," a single unit of 20552 or 20553 includes any number of injections.

5. Under fluoroscopic guidance, the pain specialist provides an interlaminar epidural injection at T10/T11 to treat pain associated with a herniated disk. Which code(s) best describe the procedure?
a. 62310, 77003
b. 62310
c. 62318
d. 64479

Correct answer: b. You should report single-injection epidurals based on the injection location, using either 62310 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62311 (??? lumbar, sacral [caudal]).

You may also report epidural injections by continuous infusion using 62318 (Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) or 62319 (??? lumbar, sacral [caudal]), as appropriate to the location.

If your physician administers a transforaminal epidural instead, report the appropriate code from the 64479 to 64484 (Injection, anesthetic agent and/or steroid, transforaminal epidural ...) range. Remember that fluoroscopic guidance (77003) is not separately payable in the ASC setting.