Article for Pain Management – Supplemental Instructions Article (A48042)


Contractor Information

 
Contractor Name 
National Government Services, Inc.
Contractor Number 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Contractor Type 
Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


Article Information

 
Article ID Number 
A48042 
Article Type 
Article
Key Article 
Yes
Article Title 
Pain Management – Supplemental Instructions Article 
AMA CPT / ADA CDT Copyright Statement 
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association.© 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
 
Primary Geographic Jurisdiction 
NumberTypeState(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B
Original Article Effective Date 
01/01/2009
Article Revision Effective Date 
01/01/2011
Article Text 
The information in this Supplemental Instructions Article (SIA) contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Pain Management. The LCD can be accessed through our contractor Web site at www.NGSMedicare.com. It can also be found on the Medicare Coverage Database at www.cms.gov/mcd.

Coding Guidelines:

General guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC:


Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-9-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed.

All procedures related to pain management procedures performed by the physician/provider performed on the same day must be billed on the same claim. Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines:

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.

The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9) , 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Fiscal Intermediary (FI) and Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Fiscal Intermediary or Part A MAC, occurrence code 32 and the date of the ABN is required.

Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, FI and Part A MAC systems will automatically deny the services.

The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.

‎If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Specific coding guidelines for this policy:

File CPT code 77003 when fluoroscopy is used or CPT code 77012 for CT guidance. Do not report CPT codes 64490–64495 unless fluoroscopic- or CT-guidance is performed. An imaging guidance code is billed only once per session. Physicians may only bill for the professional component when imaging is performed in a hospital or non-office facility. No claim should be submitted for the hard or digital film(s) maintained to document needle placement. For Paravertebral Spinal Nerves and Branches – Image guidance [fluoroscopy or CT] and any injection of contrast are inclusive components of 64490-64495.

The CPT code 72275 (Epidurography, radiological supervision and interpretation) differs from CPT code 77003 in that it represents a formal recorded and reported contrast study that includes fluoroscopy. Epidurography should only be reported when it is reasonable and medically necessary to perform a diagnostic study. It should not be billed for the usual work of fluoroscopy and dye injection that is integral to the injection(s) addressed in the policy and the supplemental instructions article.

Use CPT code 64999 (Unlisted procedure, nervous system) for pulsed radiofrequency and the denervation procedures of the sacro-iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational and therefore, not medically necessary. Sacro-iliac joint/nerve denervation procedures are also considered investigational and not medically necessary.

Unless otherwise specified in the long description, HCPCS descriptions refer to the non-compounded, FDA-approved final product. If a product is compounded and a specific HCPCS code does not exist for the compounded product, the provider should report an appropriate unlisted code such as J3490.

Acupuncture, a non-covered service, is reported with CPT codes 97810 – 97814.

Use ICD-9-CM code V72.5 only when procedure codes 62310, 62311, 62318, 62319 are used for injection of agents for diagnostic procedures unrelated to pain management (e.g., cisternography).

TRIGGER POINT INJECTIONS AND INJECTIONS OF TENDON SHEATH, LIGAMENT, GANGLION CYST, CARPAL AND TARSAL TUNNELS

For trigger point injections, use code 20552 for one or two muscle groups injected, or 20553 for three or more muscle groups. The number of services for either code is one (1), regardless of the number of injections at any individual site, and regardless of the number of sites. Only 20552 or 20553 may be billed, not both. Trigger point injections must be billed on only one line, regardless of the number of sites.

CPT code 20551 should be used when the origin or insertion of a tendon is injected, in contrast to an injection of the tendon sheath, CPT code 20550.

CPT code 28899 (unilateral procedure, foot or toe) should be billed for the injection of the tarsal tunnel.

Injection of separate sites (tendon sheath, ligament or ganglion cyst) during the same encounter should be reported on a separate line of coding and must have the modifier 59 appended. Multiple surgical rules will apply. Modifier 50 should not be reported with CPT codes 20551, 20552, 20553 or 20612, but may be reported, when appropriate, with CPT codes 20550 and 20526.

Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (NOS 001).

Claims for prolotherapy must not be reported with the trigger point codes or other injection codes.

EPIDURAL AND INTRATHECAL INJECTIONS - INTERLAMINAR AND CAUDAL AND TREATMENT OF SPASTICITY

All the CPT codes applicable to this policy include allowance for the insertion of the needle into the epidural or intrathecal space, as well as the injection of the drug.

The CPT codes 62310, 62311, 62318, and 62319 each have a bilateral surgery indicator of "0." Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.

Only one (1) unit of 62310, 62311, 62318 or 62319 should be billed and allowed per spinal region [cervical/thoracic, lumbar/sacral (caudal)], no matter how many injections are made in that region.

EPIDURAL INJECTIONS - TRANSFORAMINAL

The CPT codes 64479-64484 have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for bilateral procedures applies. When injecting a nerve root bilaterally, file with modifier –50. When injecting a nerve root unilaterally, file the appropriate anatomic modifier –LT or –RT.
  • Only one (1) unit of service should be submitted for a transforaminal epidural injection for a unilateral or bilateral injection at the same level.
Whether a transforaminal epidural block is performed unilaterally or bilaterally at one vertebral level, use CPT code 64479 or 64483 for the first level injected. If a second level is injected unilaterally or bilaterally, use CPT code 64480 or 64484.

Effective January 1, 2011 fluoroscopic or computed tomography (CT) image guidance and any injection of contrast are inclusive components of CPT codes 64479 – 64484 and should not be separately billed.

PARAVERTEBRAL JOINT/NERVE BLOCKS – DIAGNOSTIC AND THERAPEUTIC

A facet joint level refers to the zygapophyseal joint or the two medial branch nerves innervating that zygapophyseal joint.

Use CPT codes 64491 and 64492 in conjunction with 64490. Do not report CPT code 64492 more than once per day. Use CPT codes 64494 and 64495 in conjunction with 64493. Do not report CPT code 64495 more than once per day. For injection of the T12-L1 joint, or nerves innervating that joint, use 64493.

The CPT codes 64490 and 64493 have a bilateral surgery indicator of "1." Thus, they are considered "unilateral" procedures and the 150% payment adjustment for the bilateral procedures applies.
  • When injecting a facet joint/nerve bilaterally, file with modifier –50.
  • When injecting a facet joint/nerve unilaterally, file the appropriate anatomic modifier –LT or –RT.
  • Only one (1) unit of service (equals one bilateral injection or one unilateral injection) should be submitted for a unilateral or bilateral paravertebral facet joint/nerve injection.
Whether a paravertebral facet joint/nerve block is performed unilaterally or bilaterally at one vertebral level, use CPT code 64490 or 64493 for the first level injected. If a second, third or any additional level is injected unilaterally or bilaterally, use CPT codes 64491, 64492, 64494 or 64495.
  • Facet joint levels refer to the joints that are blocked and not the number of medial nerve branches that innervate them. The CPT codes 64490 and 64493 are intended to be used to report all of the nerves that innervate the first paravertebral facet joint level injected and not each nerve. CPT codes 64491, 64492, 64494 or 64495 are intended to report each additional paravertebral facet joint level and not each additional nerve.
PARAVERTEBRAL JOINT/NERVE DENERVATION

A facet joint is supplied by two medial branch nerves. Each medial branch nerve supplies sensation to one half of each facet joint above and below the spinal nerve of origin. Therefore, both of the two related medial nerve branches for each facet joint must be treated.

The CPT codes 64622-64627 have a bilateral surgery indicator of "1." Thus, they are considered “unilateral” procedures and the 150% payment adjustment for bilateral procedures applies.
  • When denervating a facet joint/nerve unilaterally, file the appropriate anatomic modifier, –LT or –RT.
  • When denervating a facet joint/nerve bilaterally at the same level, file with modifier –50.
  • One (1) unit of service may be submitted for each level of nerve denervation. For example, destruction of L3 and L4 medial branch nerves would be coded as 64622 and 64623.
Whether a paravertebral facet joint/nerve denervation is performed unilaterally or bilaterally, use CPT code 64622 or 64626 for the first level denervated. If a second level is denervated unilaterally or bilaterally, use CPT code 64623 or 64627.

Injecting any denervation agent through the needle, including small amounts of contrast or anesthetic to confirm the position of the needle is considered an integral part of the procedure and is not separately reimbursed. Neither the injection procedure nor the anesthetic or denervation agent drugs should be billed.

SACROILIAC (SI) JOINT INJECTIONS

CPT codes 27096 and G0260 should not be billed when a physician provides routine sacroiliac injections. They are to be used only with imaging confirmation of intra-articular needle positioning.

The CPT code 27096 has a bilateral surgery indicator of "1." Thus, it is considered a "unilateral" procedure. Follow the same guidelines for G0260:
  • When injecting a sacroiliac joint bilaterally, file with modifier –50.
  • When injecting a sacroiliac joint unilaterally, file the appropriate anatomic modifier –LT or –RT.
  • Only one (1) unit of service (equals one bilateral injection or one unilateral injection) should be submitted for a unilateral or bilateral sacroiliac joint/nerve injection.
CPT code G0260 should be billed by facilities paid by OPPS.

Do not bill CPT code 73542 (Radiologic examination, sacroiliac joint arthrography, radiological supervision and interpretation) for injection of contrast to verify needle position. The CPT code 73542 is only to be billed for a medically necessary diagnostic study and requires a full interpretation and report.

ACUTE POST-OPERATIVE PAIN MANAGEMENT

CPT codes 62310, 62311 should be used when the analgesia is delivered by a single injection.

These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier -59 should be used when billing these services to indicate that the catheter or injection was a separate procedure from the surgical anesthesia care.

In accordance with NCCI policy and edits, the epidural catheter insertion (CPT codes 62318 or 62319) includes the setup and start of the infusion. Therefore, the daily management of epidural or subarachnoid drug administration (CPT code 01996) should not be billed for the same day as the catheter insertion.

The time utilized for a single injection (CPT codes 62310 and 62311) or the insertion of the epidural catheter (CPT codes 62318 and 62319) should not be included in the time reported for the anesthesia care for the surgical procedure. The catheter insertion is considered a surgical procedure and should be coded with the number of services of one (1).

Do not code for the administration of any drug or other diagnostic substances used when inserting the catheter or performing the injection procedure.

The daily management of epidural or subarachnoid drug administration (CPT code 01996) is a daily service and should only be coded with a number of services (NOS) of one (1) for each day billed. Post-operative pain management services should be reported in the inpatient hospital setting (21) only.

For claims submitted to the carrier or Part B MAC

TRIGGER POINT INJECTIONS; AND INJECTIONS OF TENDON SHEATH, LIGAMENT, GANGLION CYST, CARPAL AND TARSAL TUNNELS

Injections of trigger points; and injections of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels
are payable in the following places of service: office (11), home (12), assisted living facility (13), group home/foster care setting (14), temporary lodging (16) urgent care facility (20), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (ASC) (24), skilled nursing facility (31), nursing facility (32), custodial care facility (33), independent clinic (49), comprehensive inpatient rehab facility (61), comprehensive outpatient rehab facility (62), end stage renal disease treatment facility (65) and state or local public health clinic (71). Local anesthetics are not separately reimbursed and should not be billed.

INTERLAMINAR OR CAUDAL EPIDURAL AND/OR INTRATHECAL INJECTIONS INCLUDING THOSE TREATING SPASTICITY, TRANSFORAMINAL EPIDURAL INJECTIONS, PARAVERTEBRAL JOINT/NERVE INJECTIONS AND DENERVATION, AND SACROILIAC JOINT INJECTIONS

Acceptable places of service are: office (11), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), skilled nursing facility for patients in a Part A stay (31), skilled nursing facility for patients not in a Part A stay (32), independent clinic (49), comprehensive inpatient rehabilitation facility (61), and comprehensive outpatient rehabilitation facility (62). CPT code G0260 may only be billed in the ambulatory surgery center (POS 24).

All procedures performed at a single encounter should be billed on the same claim. Indicate the level of epidural transforaminal or facet joint/nerves injected/denervated, e.g., C2/3, L5/S1, etc., in Item 19 of the CMS-1500 form or its electronic equivalent. Please also note whether all injections are diagnostic (dx) or therapeutic (tx), if applicable.

Ambulatory surgery centers (ASCs) must append modifier -KX (Requirements in the medical policy have been met) to all procedures for which fluoroscopy- or CT-guidance is medically necessary to attest to the use of such imaging. Procedures requiring medically necessary fluoroscopy- or CT-guidance include transforaminal epidural injections, paravertebral joint/nerve injections or denervations, and sacroiliac joint injections. In addition, subsequent epidural (interlaminar or caudal) injections after a failed or inadequate response to a blind injection, if performed, should be under fluoroscopic visualization or CT-guidance. Effective January 1, 2010, modifier –KX is not required for paravertebral joint/nerve injections. However, the CPT procedures codes 64490-64495 should not be reported unless fluoroscopy or CT guidance is performed.

HCPCS DRUG CODES

The HCPCS drug code is payable in the following places of service: office (11), home (12), assisted living facility (13), group home foster care setting (14) temporary lodging (16), urgent care facility (20), nursing facility (32), custodial care facility (33), independent clinic (49), end stage renal disease treatment facility (65) and state or local public health clinic (71).

A claim for services rendered in the inpatient hospital (21), outpatient hospital (22) or emergency room, hospital (23), ambulatory surgery center (24), skilled nursing facility for patients in a part A stay (31), comprehensive inpatient rehabilitation facility (61), and comprehensive outpatient rehabilitation facility (62) must indicate the name of the drug and dosage in item 19 or the electronic equivalent. The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-9-CM code reported is 726.32 and there is no injection.

The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for the procedure. Claims for local anesthetic should not be reported. The exceptions to this guideline are:
  • When services are rendered in places of services 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.
A claim for services rendered in the office or independent clinic, when the physician does not bill for the injectables, must include the name of the drug and dosage in item 19 or the electronic equivalent.

For claims submitted to the fiscal intermediary or Part A MAC

Hospital Inpatient Claims:
  • The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
  • The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.
  • For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Hospital Outpatient Claims:
  • The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).
  • The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
All procedures performed at a single encounter must be billed on the same claim. The level of epidural transforaminal or facet joint/nerves injected/denervated, e.g., C2/3, L5/S1, etc., may be indicated in form locator (FL) 80 of the UB-04, or its electronic equivalent. Please also note whether all injections are diagnostic (dx) or therapeutic (tx), if applicable.

For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.


Coding Information

 
Bill Type Codes: 

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF)
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
 
Revenue Codes: 

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

0360 Operating Room Services - General Classification
0450 Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
050X Outpatient Services - General Classification
051X Clinic - General Classification
052X Free-Standing Clinic - General Classification
0761 Specialty Services - Treatment Room
096X Professional Fees - General Classification
 
CPT/HCPCS Codes 
TRIGGER POINT INJECTIONS


20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)
20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLE(S)
INJECTION OF TENDON SHEATHS, LIGAMENTS, GANGLION CYSTS, CARPAL AND TARSAL TUNNELS

20526 INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL TUNNEL
20550 INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ’’FASCIA’’)
20551 INJECTION(S); SINGLE TENDON ORIGIN/INSERTION
20612 ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION
28899 UNLISTED PROCEDURE, FOOT OR TOES
EPIDURAL AND INTRATHECAL INJECTIONS - INTERLAMINAR AND CAUDAL

01996 DAILY HOSPITAL MANAGEMENT OF EPIDURAL OR SUBARACHNOID CONTINUOUS DRUG ADMINISTRATION
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
62311 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; LUMBAR, SACRAL (CAUDAL)
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
62319 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; LUMBAR, SACRAL (CAUDAL)
EPIDURAL INJECTIONS – TRANSFORAMINAL

64479 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE LEVEL
64480 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64483 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE LEVEL
64484 INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
EPIDURAL AND INTRATHECAL INJECTIONS - ACUTE POST-OPERATIVE CARE MANAGEMENT

01996 DAILY HOSPITAL MANAGEMENT OF EPIDURAL OR SUBARACHNOID CONTINUOUS DRUG ADMINISTRATION
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
62311 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; LUMBAR, SACRAL (CAUDAL)
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
62319 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; LUMBAR, SACRAL (CAUDAL)
PARAVERTEBRAL JOINT/NERVE BLOCKS – DIAGNOSTIC AND THERAPEUTIC

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 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64492 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; 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 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64495 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
PARAVERTEBRAL JOINT/NERVE DENERVATION

64622 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR SACRAL, SINGLE LEVEL
64623 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64626 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR THORACIC, SINGLE LEVEL
64627 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
64999 UNLISTED PROCEDURE, NERVOUS SYSTEM
SACROILIAC (SI) JOINT INJECTIONS

27096 INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY AND/ OR ANESTHETIC/STEROID
G0260 INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY
INTRATHECAL DRUGS

J0475 INJECTION, BACLOFEN, 10 MG
J0476 INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL
J0735 INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG
J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG
J2275 INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER 10 MG
J2278 INJECTION, ZICONOTIDE, 1 MICROGRAM
J3010 INJECTION, FENTANYL CITRATE, 0.1 MG
J3490 UNCLASSIFIED DRUGS
FLUOROSCOPIC GUIDANCE OR CT GUIDANCE

The following codes should be reported as indicated.



77003 FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL, SUBARACHNOID, OR SACROILIAC JOINT), INCLUDING NEUROLYTIC AGENT DESTRUCTION
77012 COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION
 
ICD-9 Codes that are Covered 
Please see LCD.
 
ICD-9 Codes that are Not Covered 
Not applicable
 


Other Information

 
Other Comments 
These supplemental instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims.
Revision History Explanation 
Article published January 2011:HCPCS coding update for 2011. Descriptor changes were made to CPT codes 20552 and 20553 in Group 1, 20526 in Group 2, 62318 descriptor in Group 3, 64479, 64480, 64483, and 64484 in Group 4, 62318 in Group 5, and 77003 in Group 10. Coding guidelines for Epidural Injections - Transforaminal were updated as follows: "Effective January 1, 2011 fluoroscopic or computed tomography (CT) image guidance and any injection of contrast are inclusive components of CPT codes 64479 – 64484 and should not be separately billed." Minor changes were made to update for NGS template.

Article published August 2010: The CPT code list for EPIDURAL AND INTRATHECAL INJECTIONS - INTERLAMINAR AND CAUDAL; EPIDURAL INJECTIONS – TRANSFORAMINAL; ACUTE POST-OPERATIVE CARE MANAGEMENT was deleted and replaced with separate lists for EPIDURAL AND INTRATHECAL INJECTIONS - INTERLAMINAR AND CAUDAL; EPIDURAL INJECTIONS – TRANSFORAMINAL; EPIDURAL AND INTRATHECAL INJECTIONS - ACUTE POST-OPERATIVE CARE MANAGEMENT; and INTRATHECAL DRUGS. No new CPT/HCPCS codes were added to the policy, and this does not represent a coding change. Other minor changes were made to update for current NGS and CMS template language and correct minor typographical errors. The LCD associated with this article was similarly updated.

Article published May 2010: The General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC section for TRIGGER POINT INJECTIONS AND INJECTIONS OF TENDON SHEATH, LIGAMENT, GANGLION CYST, CARPAL AND TARSAL TUNNELS were updated as follows: “Modifier 50 should not be reported with CPT codes 20551, 20552, 20553 or 20612, but may be reported, when appropriate, with CPT codes 20550 and 20526.” Limitation of liability guidelines revised in accordance with CMS Transmittals 1840 and 1921. The policy was reviewed and minor cosmetic changes were made to update for current NGS and CMS template language. TOB 83x was removed. The LCD associated with this policy was similarly updated.

Article published January 2010: CPT/HCPCS coding update 2010: CPT codes 64470, 64472 were deleted from group 4 (PARAVERTEBRAL JOINT/NERVE BLOCKS – DIAGNOSTIC AND THERAPEUTIC) and replaced with CPT codes 64490, 64491 and 64492. CPT codes 64475, 64476 were deleted from group 4 (PARAVERTEBRAL JOINT/NERVE BLOCKS – DIAGNOSTIC AND THERAPEUTIC) and replaced with CPT codes 64493, 64494 and 64495. The code descriptor was changed for CPT code 77003. The SIA was updated throughout to remove references to deleted codes and update for new codes.

General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC: were updated with the addition of the following: “Do not report CPT codes 64490–64495 unless fluoroscopic or CT guidance is performed.” and “For Paravertebral Spinal Nerves and Branches – Image guidance [fluoroscopy or CT] and any injection of contrast are inclusive components of 64490-64495.”

Coding instructions for Paravertebral Joint/Nerve Blocks – Diagnostic and Therapeutic were updated with the addition of the following: “Use CPT codes 64491 and 64492 in conjunction with 64490. Do not report CPT code 64492 more than once per day. Use CPT codes 64494 and 64495 in conjunction with 64493. Do not report CPT code 64495 more than once per day. For injection of the T12-L1 joint or nerves innervating that joint, use 64493.”

Coding instructions for Interlaminar or Caudal Epidural and/or Intrathecal Injections Including Those Treating Spasticity, Transforaminal Epidural Injections, Paravertebral Joint/Nerve Injections and Denervation, and Sacroiliac Joint Injections were updated with the addition of the following statement: CPT code G0260 may only be billed in the ambulatory surgery center (ASC) – POS 24. The –KX modifier instructions were updated as follows: “Ambulatory surgery centers must append modifier -KX (Requirements in the medical policy have been met) to all procedures for which fluoroscopy- or CT-guidance is medically necessary to attest to the use of such imaging unless the image guidance is included in the description of the procedure code. Procedures requiring medically necessary fluoroscopy- or CT-guidance include transforaminal epidural injections, paravertebral joint/nerve injections or denervations, and sacroiliac joint injections. In addition, subsequent epidural (interlaminar or caudal) injections after a failed or inadequate response to a blind injection, if performed, should be under fluoroscopic visualization or CT-guidance. Effective January 1, 2010, modifier –KX is not required for paravertebral joint/nerve injections. However, the CPT procedures codes 64490-64495 should not be reported unless fluoroscopy or CT guidance is performed.”

Based on CR 6338, Change Type of Bill (TOB) for Federally Qualified Health Centers (FQHCs) from 73x to 77x, the following paragraph has been added to the SIA: “For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.” Minor changes were made to reflect current template language. The local coverage determination associated with this policy was similarly updated.

Article published May 2009:

The General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC were updated by adding the following:

Use ICD-9-CM code V72.5 only when procedure codes 62310, 62311, 62318, 62319 are used for injection of agents for diagnostic procedures unrelated to pain management (e.g., cisternography).

The Carrier Billing Guidelines under INTERLAMINAR OR CAUDAL EPIDURAL AND/OR INTRATHECAL INJECTIONS INCLUDING THOSE TREATING SPASTICITY, TRANSFORAMINAL EPIDURAL INJECTIONS, PARAVERTEBRAL JOINT/NERVE INJECTIONS AND DENERVATION, AND SACROILIAC JOINT INJECTIONS were updated by adding the following:

    Ambulatory surgery centers (ASCs) must append modifier -KX (Requirements in the medical policy have been met) to all procedures for which fluoroscopy- or CT-guidance is medically necessary to attest to the use of such imaging. Procedures requiring medically necessary fluoroscopy- or CT-guidance include transforaminal epidural injections, paravertebral joint/nerve injections or denervations, and sacroiliac joint injections. In addition, subsequent epidural (interlaminar or caudal) injections after a failed or inadequate response to a blind injection, if performed, should be under fluoroscopic visualization or CT-guidance.
No change was made to the Local Coverage Determination associated with this Supplemental Instructions Article.

The changes listed in this latest version of the Supplemental Instructions Article (SIA) do NOT apply to the states of Maine (contract 00180), Massachusetts (contract 00181), or Vermont and New Hampshire (contract 00270); however, all other instructions, and requirements in the SIA remain in effect for these states.

Article published April 2009:

Place of service codes and instructions that had inadvertently been omitted were added to the section "For claims submitted to the carrier:" as follows:

INTERLAMINAR OR CAUDAL EPIDURAL AND/OR INTRATHECAL INJECTIONS INCLUDING THOSE TREATING SPASTICITY, TRANSFORAMINAL EPIDURAL INJECTIONS, PARAVERTEBRAL JOINT/NERVE INJECTIONS AND DENERVATION, AND SACROILIAC JOINT INJECTIONS

Acceptable places of service are: office (11), inpatient hospital (21), outpatient hospital (22), emergency room (23), ambulatory surgical center (24), skilled nursing facility for patients in a Part A stay (31), skilled nursing facility for patients not in a Part A stay (32), independent clinic (49), comprehensive inpatient rehabilitation facility (61), and comprehensive outpatient rehabilitation facility (62).

The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for the procedure. Claims for local anesthetic should not be reported. The exceptions to this guideline are:
  • When services are rendered in places of services 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.
HCPCS DRUG CODES

The medication being injected, designated by an appropriate HCPCS drug code should be submitted on the same claim, same day of service as the claim for the procedure. Claims for local anesthetic should not be reported. The exceptions to this guideline are:
  • When services are rendered in places of services 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported. ul type=disc>A claim for services rendered in the office or independent clinic, when the physician does not bill for the injectables, must include the name of the drug and dosage in item 19 or the electronic equivalent.

    Policy was reorganized to update for current template changes and correction of minor typographical errors.

    The changes listed in this latest version of the Supplemental Instructions Article (SIA) do NOT apply to the states of Maine (contract 00180), Massachusetts (contract 00181), or Vermont and New Hampshire (contract 00270); however, all other instructions, and requirements in the SIA remain in effect for these states.

    Article published January 2009

    05/15/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers 00180 and 00181 were removed from this Article as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

    06/05/2009 - In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number 00270 was removed from this article as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states.

    8/10/2009 - The description for Revenue code 0761 was changed
    11/15/2009 - The description for CPT/HCPCS code 77003 was changed in group 7
    11/15/2009 - CPT/HCPCS code 64470 was deleted from group 4
    11/15/2009 - CPT/HCPCS code 64472 was deleted from group 4
    11/15/2009 - CPT/HCPCS code 64475 was deleted from group 4
    11/15/2009 - CPT/HCPCS code 64476 was deleted from group 4

    3/7/2010 - The description for Bill Type Code 73 was changed
    3/7/2010 - The description for Bill Type Code 77 was changed

    8/1/2010 - The description for Bill Type Code 11 was changed
    8/1/2010 - The description for Bill Type Code 12 was changed
    8/1/2010 - The description for Bill Type Code 13 was changed
    8/1/2010 - The description for Bill Type Code 18 was changed
    8/1/2010 - The description for Bill Type Code 21 was changed
    8/1/2010 - The description for Bill Type Code 22 was changed
    8/1/2010 - The description for Bill Type Code 23 was changed
    8/1/2010 - The description for Bill Type Code 71 was changed
    8/1/2010 - The description for Bill Type Code 73 was changed
    8/1/2010 - The description for Bill Type Code 75 was changed
    8/1/2010 - The description for Bill Type Code 85 was changed

    8/1/2010 - The description for Revenue code 0360 was changed
    8/1/2010 - The description for Revenue code 0450 was changed
    8/1/2010 - The description for Revenue code 0490 was changed
    8/1/2010 - The description for Revenue code 0499 was changed
    8/1/2010 - The description for Revenue code 0500 was changed
    8/1/2010 - The description for Revenue code 0509 was changed
    8/1/2010 - The description for Revenue code 0510 was changed
    8/1/2010 - The description for Revenue code 0511 was changed
    8/1/2010 - The description for Revenue code 0512 was changed
    8/1/2010 - The description for Revenue code 0513 was changed
    8/1/2010 - The description for Revenue code 0514 was changed
    8/1/2010 - The description for Revenue code 0515 was changed
    8/1/2010 - The description for Revenue code 0516 was changed
    8/1/2010 - The description for Revenue code 0517 was changed
    8/1/2010 - The description for Revenue code 0519 was changed
    8/1/2010 - The description for Revenue code 0520 was changed
    8/1/2010 - The description for Revenue code 0521 was changed
    8/1/2010 - The description for Revenue code 0522 was changed
    8/1/2010 - The description for Revenue code 0523 was changed
    8/1/2010 - The description for Revenue code 0524 was changed
    8/1/2010 - The description for Revenue code 0525 was changed
    8/1/2010 - The description for Revenue code 0526 was changed
    8/1/2010 - The description for Revenue code 0527 was changed
    8/1/2010 - The description for Revenue code 0528 was changed
    8/1/2010 - The description for Revenue code 0529 was changed
    8/1/2010 - The description for Revenue code 0761 was changed
    8/1/2010 - The description for Revenue code 0960 was changed
    8/1/2010 - The description for Revenue code 0961 was changed
    8/1/2010 - The description for Revenue code 0962 was changed
    8/1/2010 - The description for Revenue code 0963 was changed
    8/1/2010 - The description for Revenue code 0964 was changed
    8/1/2010 - The description for Revenue code 0969 was changed

    11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays in the document:
    20552 descriptor was changed in Group 1
    20553 descriptor was changed in Group 1
    20526 descriptor was changed in Group 2
    62318 descriptor was changed in Group 3
    64479 descriptor was changed in Group 4
    64480 descriptor was changed in Group 4
    64483 descriptor was changed in Group 4
    64484 descriptor was changed in Group 4
    62318 descriptor was changed in Group 5
    77003 descriptor was changed in Group 10
 
Related Documents 
LCD(s)
L28529 - Pain Management