Update on 2020 Anesthesia and Pain Management Coding

Well friends, we are more than halfway through the first quarter and as predicted, the new CPT codes and updates are causing problems for anesthesia and pain management groups.  I have been contacted several times a day requesting help with these issues, so I decided to share our discoveries with all of you.  I can’t resolve the difficulties, but, as the saying goes, identifying the problem is half the battle.  I hope the information below will help to prevent coding and billing headaches or at least assist you in appealing incorrectly denied or improperly paid claims.

Bilateral Billing for Add-On Codes

CPT 2020 informed us of a change in reporting bilateral procedures for add-on codes. Think, for example, facet and transforaminal injections.  The base code is still reported with the -50 modifier (e.g. 64483-50).  However, the code(s) for each additional level are to be reported as two separate line items, appending modifiers -RT and -LT (64484-RT and 64484-LT).  We’ve been told so far, Medicare MACS Novitas, Palmetto and First Coast are rejecting the -RT and -LT line items. They continue to require all bilateral procedures (including add-on codes) to be billed with the 50-modifier, disregarding the new CPT instruction.   Several commercial payers are also denying this billing methodology based on utilization levels.    ACE advice is to check bilateral billing policies for all payers. If no other reference or directive is found, it is probably best to continuing to report the 50-modifier with add-on codes. 

Place of Service System Errors for Pump Analysis and Reprogramming

It has been reported that some Medicare MACs are denying pump analysis/reprograming when billed with POS 11.  We understand that Palmetto GBA Medicare has fixed this mistake, but other CMS carriers may still be incorrectly denying the service based on this system error. Carefully check denials on your pump refills/programming.

Place of Service System Errors for New Codes 64451, 62328 and 64624

Similarly, MACs are denying new CPT codes 64451, 62328 and 64624 when reported with POS 11.   Our source was specific to Palmetto GBA Medicare, who we understand has corrected the system error. However, they advised our client to wait at least 30 days before resubmitting the claims.  Be sure to pay attention to denials for these new codes and contact your payers about correcting their database tables and the recommended timeline to resubmit your claims.

Intercostal Nerve Block Codes 64420 and 64421

In the past, CPT code 64421, intercostal nerve block, multiple was a stand-alone code reported when more than one intercostal level was injected.  The 2020 CPT update changed 64421 to an add-on code to 64420. Coders are now instructed to report 64420 for the first level and 64421 for each additional level injected. It appears this was not communicated to NCCI, as the 1/1/2020 edits still bundle 64420 into 64421.  We are hoping this will be fixed with the second quarter updates effective April 1^st.The MUE for 64421 does reflect the 2020 change, allowing 3 units per day. 

Issues with New Codes for Injection or Radiofrequency of Nerves Innervating the Sacroiliac Joint

Codes 64451 (injection) and 64625 (radiofrequency ablation) of nerves innervating the SI joint are reported only once regardless of the number of nerves injected or ablated.  Since L5, S1, S2, and S3 nerves all innervate the SI joint, treating all four of these nerves would be reported with only a single code (64451 or 64625).  There is a parenthetical comment that prohibits billing codes for lumbar facet injection or denervation with these new codes.  This may be problematic for the pain physician as it is not uncommon to perform a facet injection/RF at L5-S1 (including the L4 median nerve that also innervates this joint) in conjunction with treating the nerves that innervate the sacroiliac joint.  This new instruction would negate billing for both services if performed at the same encounter.

An instruction was discovered in the Medicare MAC NGS Coding Article 52863 Pain Management related to the new sacroiliac RFA code. 

“Use CPT code 64999 (Unlisted procedure, nervous system) for pulsed radiofrequency and the denervation procedures of the sacroiliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational and therefore, not medically necessary.”

“For dates of service prior to 01/01/2020, sacroiliac joint/nerve denervation procedures using traditional or cooled radiofrequency are also considered investigational and not medically necessary and should be billed with CPT code 64999.”

“For dates of service on or after 01/01/2020, CPT code 64625 – Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) should be used to report radiofrequency ablation whether performed using traditional or cooled radiofrequency (<80 degrees Celsius).

Radiofrequency ablation for denervation whether performed using traditional, cooled, or pulsed radiofrequency is considered investigational and therefore, not medically necessary.”

Additionally, NGS Coding Article 57826 Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy states:

“For dates of service on or after 01/01/2020, CPT code 64625 should be used to report non-thermal radiofrequency modalities for facet joint denervation including chemical and low-grade thermal energy (<80 degrees Celsius). Pulsed radiofrequency ablation should be reported using CPT code 64999.”

Watch closely for non-payment policies from other Medicare MACs, Medicaid and other commercial payers.

New Introductory Notes for Somatic Nerve Injections and Summary Chart

These additions to the nerve injection section in CPT have created questions as to whether CPT has changed their policy regarding the number of somatic nerve blocks that may be reported.  The comment states: “Codes 64400-64450, 64454 describe the injection of an anesthetic agent(s) ad/or steroid into a nerve plexus, nerve or branch. These codes are reported once per nerve plexus, nerve or branch as described in the code descriptor regardless of the number of injections performed along the nerve plexus, nerve or branch described by the code.”  Some were interpreting this as a limit in reporting blocks performed in various portions of a nerve plexus. At ACE, we do not think that this was intended as a policy change.  We think their intention was to reiterate that each code is only reported once regardless of the number of actual needles/injections placed into a plexus, OR the number of actual needles/injections into a nerve OR the number of actual needles/injections into a nerve branch as found in the code descriptor.

Image Guidance and the New Chart for Extracranial Nerves, Peripheral Nerves and Autonomic Nervous System

To assist coders in determining when image guidance may and may not be reported separately, CPT created a new chart.  The chart indicates that guidance may be separately billed with codes 64400-64450 and 64455.  ACE feels that they neglected to specify that only ultrasound guidance, 76942, is allowed.  Other types of radiologic guidance remain bundled as indicated by other comments in CPT and in the NCCI bundling edits.

Clarifying the Coding for Genicular Nerve Blocks Versus IPACK Blocks

We have had several coders confused about the genicular nerve block versus the IPACK block and thought you all would appreciate a clarification.  The IPACK block floods the plane posterior to the femoral shaft in the interspace between the posterior capsule of the knee and the popliteal artery.  This space includes the terminal sensory branches of the tibial nerve, but ACE nevertheless recommends coding the procedure with 64999 based on guidance in the June 2020 publication of CPT Assistant.  Genicular nerve injections require documentation that the superolateral, superomedial and inferomedial nerves have been targeted and is reported with the new CPT code 64454.  Providers must document the specific nerves blocked to allow for correct coding of this service.  But beware, Aetna published in December of 2019 in their medical policy that genicular nerve blocks are experimental and will not be covered.  http://www.aetna.com/cpb/medical/data/800_899/0863.html

So far, 2020 has been a wild ride for coders but hang in there, together we can break this bull!  If you need any help with your anesthesia or pain coding or auditing work, please contact us at 913-648-8572.