Tendon Sheath or Tendon Origin Injections

Tendon Sheath or Tendon Origin Injections

Tendon Sheath or Tendon Origin Injections involve the injection of steroids into the tendon sheath to reduce pain and inflammation. Injection is performed with x-ray or ultrasound guidance.

CPT 20550 - Injections; single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") 

Procedure Description:

After administration of adequate anesthesia and prep and draped, the physician locates the injection site. The appropriate amount of corticosteroid, anesthetic, or anti–inflammatory drug is then injected into the aponeurosis of the tendon sheath and/or ligament.

CPT 20551 - Injections, single tendon origin/insertion  

Procedure Description:

The patient is appropriately prepped and the area anesthetized, the physician prepares the site for injection. he may use radiological guidance to identify the tendon origin when it is not possible to visually locate the site of drug delivery. he injects the appropriate amount of corticosteroid, anesthetic, or anti inflammatory drug directly at the tendon origin or insertion and then withdraws the syringe. 

Notes:

Use code 20550 for injection of the plantar aponeurosis.

Single or multiple injections into the same ligament or tendon at different sites are coded as one.

For single or multiple injections into multiple ligaments, use multiple procedure codes.

Report the Bilateral procedure injections as 20550 with 50.

Trigger Point Injections

Trigger Point Injections

Trigger point injections involve selective injection of a very small amount of anesthetic agent and
steroids into areas of pain, usually in the back, to relieve pain. Injections are made into muscles, and
coding is determined by the number of muscles injected.

Procedure description:

The patient is appropriately prepped and the area anesthetized, the provider palpates, or touches, the muscle to determine the location of a trigger point. he applies firm pressure to the trigger point to assess for referred pain and a twitch response. Then, he slowly injects the appropriate amount of corticosteroid or anesthetic into the trigger point.

CPT 20552 - Injections, single or multiple trigger points, 1 or 2 muscles 

CPT 20553 -  Injections, single or multiple trigger points, 3 or more muscles

If imaging guidance is performed, see 76942, 77002, 77021 

CPT 76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

CPT 77002 - Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

CPT 77021 - Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

Notes:

These codes are based on the number of muscles injected. Consider as two if paired muscles
are injected.

Guidance is coded once per patient encounter, regardless of the number of regions treated.

Modifier 91

Modifier 91

Repeat Clinical Diagnostic Laboratory Test

Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient.  

CPT codes for use with modifier 91 are in the laboratory code range 80047-89398.

Appropriate Usage:

In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of modifier 91. 

For example: A 68 year old diabetic patient.  perform a glucose test, which reveals hypoglycemia. then administer glucose gel to the patient and retest him 15 minutes later, at which point his glucose is normal and he returns home.

In this case, you should report the appropriate lab test code such as 82947, Glucose; quantitative, blood [except reagent strip], followed by a second line item of 82947 with modifier 91.

But you might also use modifier 91 when a single code describes the same test for different analytes or organisms. In this case, codes 87804 and 87400 can describe an influenza A or influenza B test.

If your payer recommends using modifier 91 to indicate that you performed the test twice, once for type A and once for type B, you may do so.

Note:

Do not use 91 if the lab runs the test again for the following reasons,



• To confirm initial results
• Because of testing problems related to specimens or equipment
• For any other reason when a normal, one-time reportable result is all that the physician needs for appropriate patient treatment.
 
Difference between 59 and 91 modifier.

If the same test was performed on different sites, use modifier 59 instead of 91.
For example, if two wound cultures were taken from two different wound sites, modifier 59 would be appended to the second wound culture code. However, if a second culture was taken of the same wound site, then it would be appropriate to append modifier 91 to the second wound culture code.

Nerve Root Blocks

Nerve Root Blocks (Transforaminal Epidural Injection)

Nerve root blocks involve the selective injection of anesthetic agent and steroids via a transforaminal
approach adjacent to a nerve root to relieve pain in that nerve root distribution. This also describes
the transforaminal approach to epidural steroid injection at a localized level. This approach
may be performed after failed caudal epidural steroid injection therapy.

Procedure Description:

A cervical or thoracic transforaminal injection is commonly performed in cases of radiculopathy or radiculitis. Under the guidance of a fluoroscope, the physician identifies the cervical or thoracic vertebrate and its nerve root. The skin and subcutaneous tissue are anesthetized. A contrast material is injected to identify the area of the joint in relation to the needle tip. Then the physician administers a combination of anesthetic and steroid medication into the neuroforaminal epidural space.

Nerve Root Blocks - Cervical or Thoracic,

 

CPT 64479 - Injections, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 

CPT 64480 - Injections, 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) 

Nerve Root Blocks -  Lumbar or Sacral

CPT 64483 - Injections, anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 

CPT 64484 - Injections, 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) 

Notes:

These codes are per level, per side treated. If one side is treated in a region, use the code once. If both sides are treated, use 50 modifier.

Do not use code 77003, 77012, or 76942, as guidance is bundled for transforaminal epidural
injections

Use codes 0228T-0231T for transforaminal epidural injections using ultrasound guidance.

0228T -  Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level 

0229T - Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) 

0230T - Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level 

0231T - Injections, anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure)

Use unlisted code 22899 for injection of an anesthetic/steroid combination into a synovial cyst
via a laminar osteotomy.

Facet Injections

Facet Injections

Facet injections involve injection of an anesthetic agent or a steroid into the facets of the spine to relieve pain.

Facet Injections CPT Codes for cervical or thoracic level,

For the first level in the cervical or thoracic region, report 64490

For a second level in the cervical or thoracic region, report add on code 64491

For the third level and beyond, report add on code 64492.

CPT : 64490 - Injections, diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic, single level.

Procedure Description:

The physician preps and anesthetizes the patient for a facet joint injection. The physician then inserts the needle through the skin, and he advances it to the proper position within the joint using either fluoroscopy or CT imaging guidance. He then injects the therapeutic or diagnostic agent, like a steroid or anesthetic mixture. He then removes the needle and ensures that the site obtains hemostasis. 

CPT : 64491 - Injections, 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) 

CPT : 64492 - Injections, 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)

Do not separately code for multiple injections at the same spinal level. 

Report code 64490 once for the first level, example C3 to C4, 

Report add on code 64491 once for the second level, example C4 to C5, and 

Report add on code 64492 once for any additional levels.

Facet Injections CPT Codes for lumbar or sacral,

For the first level in the lumbar or sacral, report 64493

For a second level in the cervical or thoracic region, report add on code 64494

For the third level and beyond, report add on code 64495. 

CPT : 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 

Procedure Description:  

In this service, the physician preps and anesthetizes the patient for a facet joint injection. The physician then inserts the needle through the skin, and he advances it to the proper position within the joint using either fluoroscopy or CT imaging guidance. He then injects the therapeutic or diagnostic agent, like a steroid or anesthetic mixture. He then removes the needle and ensures that the site obtains hemostasis.

CPT : 64494 - Injections, 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) 

CPT : 64495 - Injections, 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) 

Do not separately code for multiple injections at the same spinal level. 

Report code 64493 once for the first level, example L3 to L4, 

Report add on code 64494 once for the second level, example L4 to L5, and 

Report add on code 64495 once for any additional levels.

Notes:

If one side is treated in a region, use the code once. If both sides are treated, Use a 50 modifier.

Fluoroscopy or CT guidance are bundled into facet blocks. 

Injection of small amount of contrast to confirm the needle position is also included can not be coded separately.

Use codes 0213T-0218T for ultrasound guided facet or medial nerve root blocks.

Use unlisted code 64999 to describe injection of botulism toxin into a facet joint.

Use unlisted code 64999 for injecting an anesthetic agent around implanted spinal hardware.

Epidural Steroid Injection

Epidural Steroid Injection

Epidural steroid injection involves injection of an anesthetic agent along with a steroid into the epidural space to relieve pain.

Injecting steroid can decrease inflammation associated with common conditions such as spinal stenosis, disc herniation, or degenerative disc disease.

CPT 62310 and 62311 are usually used to describe epidural injection procedures from a caudal
approach. 

Fluoroscopy is reported separately with Code 77003 and is coded once per session. 

*Therefore, if two cervical and one thoracic level were treated, code 77003 would be used only once
CPT : 62310 - Injections, of diagnostic or therapeutic substances (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic

Procedure Description:

The patient is appropriately prepped and anesthetized, the physician uses fluoroscopic guidance to advance a needle into the skin, focusing it toward the epidural space. The physician injects a contrast material to confirm the location of the needle, taking care to avoid any injury to the nearby nerve roots and spinal cord. The physician injects epidural steroid solution and monitors the patient for 15–20 minutes after the injection. After the procedure, the provider extracts the needle, flushes the site with sterile saline, and applies gauze over the site of needle insertion.

CPT : 62311 - Injections, of diagnostic or therapeutic substances (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) 

Procedure Description:

The patient is appropriately prepped and anesthetized, the physician uses fluoroscopy guidance, a needle is inserted into the skin and directed toward the epidural space. Once the needle is in the proper position, contrast is injected to confirm the needle location. The epidural steroid solution is then injected. Following the injection, the patient is monitored for 15 to 20 minutes.  After the procedure, the provider extracts the needle, flushes the site with sterile saline, and applies gauze over the site of needle insertion.

There are three common methods for delivering steroid into the epidural space: the interlaminar, caudal, and transforaminal approaches. All three approaches entail placing a thin needle into position using fluoroscopic (x–ray) guidance. An interlaminar ESI, often referred to simply as an ‘epidural injection', involves placing the needle into the back of the epidural space and delivering the steroid over a wider area.The caudal approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space.

Note:
Injection of small amount of contrast to confirm the needle position is part of the procedure and its not coded separately.

Evaluation and Management Services

Evaluation and Management Services:

E/M services refer to visits and consultations furnished by physicians and the following
qualified professionals,
Nurse practitioners, 

Clinical nurse specialists, 

Certified nurse midwives and Physician assistants.  

SELECTING THE E&M: 

Billing Medicare for an E/M service requires the selection of a Current Procedural Terminology code that best represents,

1. Patient type

2. Setting of service

3. Level of E/M service performed.  

PATIENT TYPE:

For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.  

A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner or another physician of the same specialty who belongs to the same group practice within the previous three years. 

An established patient is an individual who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the previous three years.

SETTING OF SERVICE:

E/M services are categorized into different settings depending on where the service is furnished. Examples of settings include,

1. Office or other outpatient setting
2. Hospital inpatient
3. Evaluation and Management Services Guide
4. Emergency department
5. Nursing facility

LEVEL OF EVALUATION AND MANAGEMENT SERVICE PERFORMED

The code sets used to bill for E/M services are organized into various categories and levels. In general, the more complex the visit, the higher the level of code the physician may bill within the appropriate category. 

In order to bill any code, the services furnished must meet the definition of the code. It is the physician’s responsibility to ensure that the codes selected reflect the services furnished. 

There are three key components when selecting the appropriate level of E/M service provided: 

1. History, 

2. Examination, and 

3. Medical decision making. 

Visits that consist predominately of counseling and/or coordination of care are an exception to this rule. 

For these visits, time is the key or controlling factor to qualify for a particular level of E/M services

A. History:

Consists of 3 Major components are mentioned below,

1. HPI

2. ROS

3. PFSH

Chief Complaint :
A Chief Complaint is describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The Chief Complaint is usually given by the patient. For example, patient complains of chest pain.

HPI (History of Present Illness)

HPI is the description of the development of the patient’s present illness.

HPI elements are listed below,

1. Location
2. Quality 

3. Severity 

4. Duration 

5. Timing 

6. Context 

7. Modifying factors 

8. Associated signs and symptoms.

There are two types of HPI:  

1. Brief and 

2. Extended.

A brief HPI includes documentation of one to three HPI elements. 

A extended HPI includes documentation of four or more HPI elements.

ROS: Review of Systems

ROS is obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized for ROS purposes:

1. Constitutional Symptoms (for example, fever, weight loss)
2. Eyes,

3. Ears, Nose, Mouth, Throat,

4. Cardiovascular, 

5. Respiratory, 

6. Gastrointestinal, 

7. Genitourinary, 

8. Musculoskeletal,

9. Integumentary (skin and/or breast); 

10. Neurological,

11. Psychiatric,

12. Endocrine,

13. Hematologic/Lymphatic; and 

14. Allergic/Immunologic.

There are three types of ROS: 

1. Problem pertinent, 

2. Extended, and 

3. Complete

A problem pertinent ROS- Minimum one system is reviewed
Extended ROS - Two to nine systems were reviewed
Complete ROS - Minimum of ten systems were reviewed

PFSH - Past, Family, and/or Social History 

PFSH consists of a review of three areas:

1. Past history including experiences with illnesses, operations, injuries, and treatments.
2. Family history including diseases, and hereditary conditions that may place the patient at risk.
3. Social history including an age appropriate review of past and current activities.

 The two types of PFSH are:

1. Pertinent and
2. Complete

The pertinent PFSH must document at least one item from any of the three history areas.
Complete PFSH is a review of two history areas is sufficient.

Note:
The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.