CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Q: When our pain doc does 62311 (lumbar epidural) with G0260 (SI joint injection), I looked at CCI and it says 62311 is bundled; however, you can use a modifier to differentiate between services, and to modify 62311. What documentation would I use to justify this -59?
Leslie Johnson, CCS-P, CPC, Director of Coding and Education, Medi-Corp. I've actually been doing research on this subject and have found two separate reasons that are acceptable to payors and to Medicare for why/when a modifier -59 is appropriate to use on the 62311 when done at the same encounter as the G0260.
There needs to be a distinct reason for doing both procedures. It's fact that some medial branches innervate the sacral area, so they will do a medial branch block with an sacroiliac (SI) joint injections to treat the same kind of pain. Ditto for when they might do a caudal epidural steroid injection (ESI) and an SI joint pain injection. This is a "double whammy" for the same problem so we need to be careful and look at where they're injecting, and the reason for the injection. In those cases I mentioned above, you would only code for the SI joint injection because the other two types of injections are for similar reasons, and are considered inclusive.
Where the needle actually goes and the intent of the procedure will determine whether or not modifier -59 should be on the inclusive code. I've found, in the "utilization" information found in the policies, that some payors specifically state that if, in the course of treating one problem, a new one comes up or new symptoms pop up, then it may be appropriate to code out both procedures and get paid for both. This should be evident in the documentation.
Example: Patient comes in with low back pain, an ESI was ordered with a follow-up in 10 days. During this follow-up period, the low back pain eases, but a new symptom emerges — pain that could be pelvic or lower than the original low back pain.
So on the next visit, the physician may decide to do an ESI to treat the low back pain, and the SI joint injection to treat the low-low back or sacral region pain. Same diagnosis, but for different reasons. Documentation should show this, and you should be able to win an appeal and/or be justified in using modifier -59 based on this kind of documentation when you bill 62311-59 and the G0260.
The second reason — and I was a bit shocked by this one — is for why they might do multiple injections. In the utilization information, payors (especially Medicare) state that "it's not expected that an ESI would be performed in conjunction with SI joint injection, trigger point, selective nerve root blocks" etc. Again, different modalities appear to be used to treat the same issue. It may actually be so, but there may be other reasons that the docs may be thinking but aren't documenting.
Check your reports and H&P for coumadin or plavix or other types of anti-coagulants. I see in my physicians wording like this: "patient was instructed to stop taking the coumadin for" X amount of days prior to the procedure. It's very risky for a patient to stop taking their anticoagulation meds for any amount of time. So what a pain management physician might do is two or three different injection treatments at the same time to avoid having the patient stop taking these lifesaving meds too many times and being exposed to clotting/stroke risk. Some carriers instruct us to use the ICD-9 V58.61 on the claim along with the reason for the injections. This will signify that the patient is at (anticoagulant) risk, and the multiple injection modalities will be allowed even if the treatment is aimed at the same problem.
This is something I've been instructing my physicians to put on their reports so I can see what he's doing/thinking, that is, IF this is what they are thinking/doing. I wouldn't go so far as to presume that this is their thought, just because a patient has been instructed to stop taking these meds, and that this is why they are doing the multiple injections on the same date of service — I'm not a clinician. However, if this is in their mind and they document it, I won't hesitate in using this diagnosis along with the others and appropriate modifiers.
This information that I'm telling you above can be found in the LCD and other payor policies — and not all of them mention the anticoagulant danger. Sometimes it's found within all the clinical data, but with Medicare LCDs, this information is usually found in bold print under all the diagnoses/CPT tables under a subheading which includes "utilization."
Contact Leslie Johnson at ljohnson@medi-corp.com. Learn more about Medi-Corp.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.