E/M on Same Day as an Injection

Question:

My pain management physician saw a patient in the office and the chief complaint states that the patient is here for a trigger point injection (20552).  He has documented a detailed history, expanded problem focused examination and the decision making is low complexity since the patient is established and the pain is worsening.  Can I bill 99213-25 and the trigger point 20553 together?

Answer:

In order to report an E/M service with Modifier 25 on the same day as another procedure or service the service must be separately identifiable and goes above and beyond the preoperative work for the injection, an E/M can be reported if the patient’s condition required a significant E/M service on the day a procedure or service identified by a CPT code was performed.

• Above and beyond other service provided
• Beyond the usual preoperative and postoperative care associated with the procedure that was performed
• Different diagnosis is not required

However, based on the reason for the visit, “patient here for trigger point injection”, and the intent of the visit is the injection, the E/M service is included in the preoperative workup and not reported separately. Keep in mind there is an Inherent E/M service in every procedure.

*This response is based on the best information available as of 12/13/18.

Thoracic Nerve Blocks

Question:

If I perform three separate injections at three intercostal levels can I report 64420 and 64421 x 2?

Answer:

No you should report 64421 (Injection, anesthetic agent; intercostal nerves, multiple, regional blocks). CPT code 64420 is used for a single injection and CPT 64421 is reported for multiple intercostal nerve blocks even when the injections are at three levels.

*This response is based on the best information available as of 06/28/18.

Piriformis Syndrome

Question:

What code do I use when my physician injects the piriformis muscle for piriformis syndrome under ultrasound guidance in the office? Do I report 64445 for the nerve injection?

Answer:

CPT code 20552 and 76942 for the ultrasound guidance. Per CPT Assistant April 2012; there is a significant difference in the work and procedure, as well as intent, between an injection of the piriformis muscle and the perineural injection of the sciatic nerve. The sciatic nerve injection code (64445) should not be used to report a piriformis injection. Piriformis muscle injection(s) should be reported using CPT code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

*This response is based on the best information available as of 06/14/18.

Steroid Injection

Question:

How do I code a left hip intraarticular steroid injection under fluoroscopic guidance?

Answer:

You would report CPT 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance) for the injection and CPT 77002 for the fluoroscopic guidance which can be reported in addition to the injection.

*This response is based on the best information available as of 05/17/18.

Coding for Paravertebral Blocks

Question:

What are the codes 64461-64463 used for?

Answer:

These codes are used to treat acute and chronic pain which includes thoracic pain after mastectomy or multiple rib fractures.  The block (paravertebral or paraspinous) targets the intercostal and spinal nerves and branches.  CPT 64461 is used for a single injection and 64462 is the add-on code for the second and any additional injection site.  Code 64463 is used for continuous infusion by catheter.  Imaging guidance is included and CPT code 64462 can only be reported once per day.

*This response is based on the best information available as of 03/29/18.

Spinal Hardware Block

Question:

How is a spinal hardware block coded?

Answer:

There is not a specific CPT code for a spinal hardware block.  Use an unlisted code 64999. When reporting an unlisted code to describe a procedure or service, it is necessary to submit supporting documentation with the claim to provide an adequate description of the nature, extent, and necessity for the procedure; and the time, effort, and equipment necessary to provide the service.

*This response is based on the best information available as of 03/15/18.