Understanding Common Pain Management Procedures for Coders
If you understand common pain management procedures, how they are performed and why are they medically necessary to be rendered to patients will surely help you code accurately. Though we know that our physicians are suppose to be responsible for their codes. But I also think we can responsibly be aware of how codes are being presented on the claims. We need to help our physicians. If we know how to code the proper way, then talk to your physician.
Here are some Procedures that you want to get a better understanding.
Transforaminal Epidural Injection
A transforaminal epidural injection is a neural blockade technique used in chronic pain management. The block can be performed for diagnostic or therapeutic purposes.
A selective block is performed of the cervical, thoracic, lumbar or sacral nerve roots with proximal spread of contrast/local anesthetic through the neural foramen to the epidural space. Imaging is utilized to ensure the needle tip is placed within or adjacent to the lateral margin of a neural foramen. Contrast material is injected to verify correct needle placement, determine abnormal filling patterns consistent with foraminal, lateral recess or nerve root pathology, and to identify unwanted vascular or intrathecal uptake. A small volume of local anesthetic is injected in order to perform a diagnostic, reproducible blockade of a specific nerve root.
Therapeutic blocks include a local anesthetic test dose to confirm proper placement (preventing inadvertent arterial injection) followed by injection of anesthetic, antispasmodic and/or anti-inflammatory substances for the long-term control of pain.
The primary diagnostic value of transforaminal epidural injection is to determine whether pain is somatic, visceral or functional. The following diagnostic scenarios may be appropriate for this service:
- When there is a question of intercostal neuralgia vs. thoracic facet syndrome
- When radiologic studies have demonstrated an abnormality related to an adjacent nerve root only
- When a clinical picture is suggestive, but not typical, for both nerve root and distal nerve or joint disease and multiple sources of pain are in question (e.g., there is a root dysfunction from mid lumbar disk disease vs. a causalgia-like syndrome from an old, chronic knee injury)
- When a discrepancy exists between the demonstrated pathology and the complaint or findings (e.g., when the source of pain appears to be due to a classic mono-radiculopathy, yet the neurodiagnostic studies have failed to provide a structural explanation or an L4 disc bulge is seen, radiologically, with an S1 root syndrome)
- When it needs to be known if the origin of the pain is central or peripheral (e.g., leg pain following spinal cord injury)
Transforaminal epidural injections may be appropriate for the following therapeutic situations:
- When radicular pain is resistant to or there is a patient with a contraindication to other therapeutic measures (such as non-narcotic analgesic, physical therapy, etc)
- When surgery is contraindicated
- When post-decompressive radiculitis or post–surgical scarring exists
- When there is monoradicular pain, confirmed by diagnostic blockade, in which a surgically correctable lesion cannot be identified
- When treatment of acute herpes zoster pain or post-herpetic neuralgia is needed
- When there is reflex sympathetic dystrophy, causalgia or a complex regional pain syndrome I and II, in lieu of a sympathetic blockade
Transforaminal epidural injections are considered to be not reasonable and necessary for the treatment of low back pain associated with “myofascial pain syndrome,” or for the treatment of a soft-tissue source of pain in which no nerve root pathology exists.
Due to the inherent risk with transforaminal epidural injections (specifically with the cervical procedures and risk of inadvertent arterial injection and L1 and L2 procedures and the risk of inadvertent injections into the artery of Adamkiewicz), physicians performing this procedure should have substantial and specific experience with transforaminal epidural injections and a clear understanding of the patient risks involved.
The standard of care for all transforaminal epidural injections in the treatment of chronic pain requires that these procedures be performed under imaging guidance. Therefore, injections for chronic pain performed without imaging guidance are considered not reasonable or necessary.
Paravertebral Facet Joint Block
Paravertebral facet joint block is used to both diagnose and treat lumbar zygapophysial (facet joint) pain. Facet joint pain syndrome is a challenging diagnosis as there are no specific history, physical examination or radiological imaging findings that point exclusively to the diagnosis. However, this diagnosis is considered if the patient describes nonspecific, achy, low back pain that is located deep in the paravertebral area. A detailed physical examination of the spine should be performed on all patients. Radiological imaging is often done as part of the workup of persistent chronic back pain to exclude other diagnoses.
Facet joint block is one method used to document/confirm suspicions of posterior elemental biomechanical pain of the spine. Often the patient presents with chronic neck, thoracic or back pain that lacks a strong radicular component, has no associated neurologic deficits, and is often aggravated by hyperextension or rotation of the spine. This policy defines chronic pain as continuous or intermittent pain that has been unresponsive to conservative measures, persisting three months or more.
Facet joint injections must be performed under imaging guidance to assure accurate placement of the needle in the facet joint or on the medial nerve branch of the facet joint. A long acting local anesthetic or corticosteroid agent is injected to temporarily denervate the facet joint. After a satisfactory block has been obtained, the patient is asked to indulge in the activities that usually aggravated his/her pain and to record his/her impressions of the effect of the procedure 4-8 hours after the injection. Temporary or prolonged abolition of the spinal pain suggests that facet joints were the source of the symptoms.
For performance of paravertebral facet joint injections, pain must have been present for greater than 3 months. A detailed pain history is essential and must provide information about prior treatments and responses which may include, but not be limited to, analgesics and physical therapy.
Diagnostic blocks are used to assess the relative contribution of sympathetic and somatosensory nerves in relation to the pain syndrome and to localize the nerve(s) responsible for the pain or neuromuscular dysfunction, particularly when multiple sources of pain are potentially present.
Imaging guidance must be used for both diagnostic and therapeutic injections to assure that the injection is properly placed.
Similarly, injections of the sacroiliac joint may be used to diagnose the cause of or to treat low back pain.
The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. Anatomically and biomechanically, the sacroiliac joint shares all its muscles with the hip joint and is thus subjected to the unidirectional pelvic shear, repetitive and torsional forces which can contribute to SI joint pain.
Pain arising from the SI joint may mimic pain originating from the lumbar disc, lumbar facet, or hip joint. Additionally, pain coming from the SI joint is not confined to pain originating only from the joint; it can originate from both intra and extra-articular structures. Except in the presence of clear pathology (tumor, fracture, infection), clinical diagnosis of SI joint pain is difficult and often one of exclusion.
The differential diagnosis of SI joint pain requires a detailed history and thorough physical exam. Imaging with radiographs, MRI, bone scans and CT scans do not consistently differentiate symptomatic from asymptomatic individuals.
SI joint injection can be done diagnostically or therapeutically. These are defined as follows:
- Diagnostic injections – either an anesthetic is injected for immediate pain relief or contrast media is injected into the joint for evaluation of the integrity (or lack thereof) of the articular cartilage and morphologic features of the joint space and capsule.
- Therapeutic injections – a steroid and/or anesthetic is injected into the SI joint for immediate and potentially lasting pain relief.
Imaging guidance ensures optimal access to the SI joint space in diagnostic procedures but may not be necessary for therapeutic SI injections. CPT code 27096 requires the use of imaging confirmation of intra-articular needle positioning.
When sacroiliac joint dysfunction is present in conjunction with other primary pain generators (such as lumbar radiculitis secondary to degenerative disc disease or lumbar facet arthropathy secondary to lumbar facet arthritis), treatment should first address the non-sacroiliac joint pain generators, as SI joint dysfunction may resolve once these pain generators have been successfully treated. If there is residual sacroiliac joint pain, it may be appropriate to perform SI joint injections to address the remaining pain.
The decision to treat chronic pain by invasive procedures must be based on a systematic assessment of the location, intensity and pathophysiology of the pain. Each injection must be individually evaluated for clinical efficacy.
Transforaminal epidural injections, paravertebral facet injections or sacroiliac joint injections, whether diagnostic or therapeutic, must be in keeping with the most current evidence-based practice guidelines.
Provision of a transforaminal epidural injection ( 64479, 64480, 64483, 64484) and/or paravertebral facet joint injection ( 64490, 64491, 64492, 64493, 64494, 64495) on the same day as an interlaminar or caudal (lumbar, sacral) epidural ( 62311)/intrathecal injection sacroiliac joint injection ( 27096), lumbar sympathetic block ( 64520) or other nerve block is considered to be not medically reasonable and necessary. If more than one procedure is provided on the same day, physicians and/or facilities must bill for only one procedure.
Diagnostic blocks for all of these procedures are usually administered in two sessions, one to two weeks apart. During the first session, usually a short-acting anesthetic is used and during the second session, a long-acting anesthetic may be used. The patient then records his/her response to pain.
Therapeutic blocks are performed after the diagnosis is established. These blocks typically include the use of anesthetic, corticosteroid substances or both for long-term control of pain.
A series of injections may be medically necessary to establish consistency of results, particularly if diagnostic blocks are to be followed by neurolysis. If successful, it is reasonable to repeat this series for a relapse. However, long term multiple nerve blocks over a period of several weeks or months is not an effective method of chronic pain management, therefore; it is not generally considered reasonable and necessary to perform transforaminal epidural or paravertebral facet joint nerve blocks more than (4) injections per region, per year. It will not be considered medically necessary to perform more than four SI joint injections per region per year.
Therapeutic transforaminal epidural or paravertebral facet joint nerve blocks exceeding two levels (bilaterally) on the same day will be denied as medically unnecessary. The billing of CPT codes 64492 and 64495, if billed bilaterally, will be considered medically unnecessary. A maximum of three levels PER REGION may be considered for reimbursement when either of the above blocks is performed and billed unilaterally. (indicated with an LT or RT modifier)
Repeat therapeutic transforaminal epidural or paravertebral facet joint nerve blocks at the same level or repeat SI joint injections, in the absence of a prior response demonstrating > 50% relief of pain lasting at least six weeks, will be denied as medically unnecessary.
Once a diagnostic transforaminal epidural or paravertebral facet joint nerve block is negative at a specific level or a diagnostic SI joint block is negative, no repeat interventions should be directed at that level, and will be considered not medically necessary, unless there is a new clinical presentation with symptoms, signs and diagnostic studies of known reliability and validity that implicate that level.
Reference Source: They are all defined and stated from the Local Coverage Determination (LCD): Transforaminal Epidural, Paravertebral Facet and Sacroiliac Joint Injections (L27512)
– Revision Effective Date For services performed on or after 09/01/201
CPT Code Book 2011, 2012, 2013, 2014,
Additional Reading Source: ( Books published by Laxmaiah Manchikanti, MD )
- Principles of Documentation, Billing, Coding & Practice Management for the Interventional Pain Professional. 2004
- Interventional Pain Management: Low Back Pain – Diagnosis and Treatment. 2002
- Interventional Pain Management: Documentation, Coding, and Billing – A Practical Guide for Physicians and ASCs. 2002