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Documenting and billing for facet joint injections

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Anesthesiologists and pain specialists need to pay special attention to billing and documenting facet joint injections as this area is prone to errors.

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Documenting and billing for facet joint injections

  1. 1. Documenting and Billing for Facet Joint Injections Anesthesiologists and pain specialists need to pay special attention to billing and documenting facet joint injections as this area is prone to errors. Outsource Strategies International 8596 E. 101st Street, Suite H Tulsa, OK 74133
  2. 2. www.outsourcestrategies.com 918-221-7769 Located at the back of the spine, facet joints connect the vertebrae together and are one of the most common and significant sources of back and neck pain. Facet joint blocks or injections are performed in an office-based procedure suite or in an ambulatory surgical center. Anesthesiologists and pain specialists need to pay special attention to billing and documenting facet joint injections as this is a potential high risk area for “fraud and abuse”, according to a www.anesthesiallc.com report. Outsourcing medical billing and coding to an expert is the best option to report facet joint injections correctly. Their teams keep track of constantly changing codes and guidelines and can help physicians submit accurate claims. Facet Joint Syndrome Healthy facets joints have cartilage, are lubricated with synovial fluid, and are covered by a joint capsule. The vertebrae glide smoothly against each other. Facet joint syndrome is caused by degenerative changes to these joints caused by aging, pressure overload of the joints, and injury. This narrows the space between each vertebra and eventually the cartilage breaks down and causes the bones to rub against each other. Bone spurs may form and as they grow larger, will extend into and narrow the spinal canal. This condition is called spinal stenosis. The main symptoms of facet joint syndrome are pain, soreness and stiffness. Prolonged periods of inactivity like sitting or standing too long can cause pain. Changing positions often improves pain. pain management options include medication, joint injections, nerve blocks, physical therapy, and nerve ablations. Patients with chronic symptoms may require surgery to repair the joint.
  3. 3. www.outsourcestrategies.com 918-221-7769 CPT Codes for Facet Joint Injections A minimally-invasive procedure, the facet joint block or injection involves using fluoroscopy or CT imaging to inject a local anesthetic and/or medication into the facet joint to numb the joint provide pain relief. There are 6 CPT codes for facet joint injections and medial branch nerve block procedures: 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic, single level +64491 …second level (list separately in addition to code for primary procedure) +64492 …third and any additional level(s) (list separately in addition to code for primary procedure) 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level +64494 …second level (list separately in addition to code for primary procedure) +64495 …third and any additional level(s) (list separately in addition to code for primary procedure) Facet Joint Injections – Reporting Guidelines  CPT 64490-64495 should be reported once per level, per side, regardless of the number of needle placements that are required. For e.g., report: - If injections are performed on both sides of one vertebral level, report CPT codes 64490 or 64493 with modifier 50 Bilateral procedure.
  4. 4. www.outsourcestrategies.com 918-221-7769 - If a second level is injected bilaterally, add-on code (64491 or 64494) should be reported with modifier 50.  Imaging guidance is bundled into facet joint injections and many of the other pain procedures that anesthesiologists perform. Therefore, when reporting facet joint codes, image guidance cannot be billed separately.  If ultrasound guidance is used for fluoroscopy and computed axial tomography, CPT guidelines state that the facet joint injection should be reported using 0213T-0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance….  If no imaging is used, CPT codes 20552-20553 Injection(s); single or multiple trigger point(s)…. should be reported. New Imaging Guidance Instructions in CPT 2019 Providers need to pay attention to new instructions specific to imaging guidance in CPT 2019 (www.asahq.org). The new CPT instruction is: “When imaging guidance or imaging supervision and interpretation is included in a surgical procedure, guidelines for image documentation and report, included in the guidelines for Radiology (Including Nuclear Medicine and Diagnostic Ultrasound), will apply.” The referenced text from the Radiology Guidelines is as follows: “Imaging may be required during the performance of certain procedures or certain imaging procedures may require surgical procedures to access the imaged area. Many services include image guidance, and imaging guidance is not separately
  5. 5. www.outsourcestrategies.com 918-221-7769 reportable when it is included in the base service. The CPT code set typically defines in descriptors and/or guidelines when imaging guidance is included. When imaging is not included in a surgical procedure or procedure from the Medicine section, image guidance codes or codes labeled “radiological supervision and interpretation” (RS&I) may be reported for the portion of the service that requires imaging. All imaging guidance codes require: (1) image documentation in the patient record and (2) description of imaging guidance in the procedure report. All RS&I codes require: (1) image documentation in the patient’s permanent record and (2) a procedure report or separate imaging report that includes written documentation of interpretive findings of information contained in the images and radiologic supervision of the service.” Take Care to Avoid Common Billing Errors As the HHS Office of the Inspector General (OIG) has found coding and billing errors in claims for facet joint injections, they come in for intense scrutiny. One common error identified by the HSS Office involved bilateral injections, where a bilateral injection was reported by listing the base code for the first side to code for primary procedure and the add-on code for the second side at the same level (www.aapc.com). Providers should also be knowledgeable about Medicare carrier policies (Local Coverage Determinations) and applicable private payer policies on facet joint and other pain medicine injections. Common documentation errors to watch out for include: - Missing documentation or documentation lacking a description of the procedure performed
  6. 6. www.outsourcestrategies.com 918-221-7769 - Not including cervical or lumbar levels, and other details - Documentation does not support the diagnosis and demonstrate medical necessity Partnering with an experienced medical billing and coding service provider can help providers ensure clean claim submission and receive appropriate reimbursement for facet joint injections.

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