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ADMIN
12-29-2011, 03:30 PM
New CPT Code Changes for Chronic Pain in 2012

The following constitutes a synopsis of the major CPT Code changes affecting chronic pain for 2012. These are not just Medicare changes; these affect all payers, since these are CPT Code changes.


1. Fluoro for SIJ injections has been bundled. You can’t circumvent the bundling by attempting to bill an arthogram, since the arthogram code, 73542, has been completely deleted from the CPT Code. Therefore, 73542 needs to be deleted from your charge ticket.


2. Fluoro for RF of the facet nerves/joints has been bundled.


3. Speaking of RF, the facet RF codes have been renumbered. So, your charge ticket will need to eliminate 64622-64627, and insert in its place 64633 (C/T), 64634 (C/T add-on code for each additional level), 64635 (L/S), and 64636 (L/S add-on code for each additional level). Critically important to understand is that coding for RF’s will change. Your templates need to change. Whereas before, we coded RF’s by nerve (i.e., L3, L4, and L5 = 3 levels), the new CPT codes limit coding to “each joint.” The AMA has published explanatory guidance in its book, “CPT Changes 2012: An Insider’s View,” stating that coding will be by joint interspace, not nerve, so that L3, L4, and L5, will be transformed into L3-4 and L4-5, resulting in a billing of 2 levels, not 3 levels. In other words, you will lose one level. The CPT Code also advises that if T12-L1 is “RF’ed,” use the C/T code, not the L/S code.


4. As a result of fluoro being bundled for: (1) facets in 2010, (2) transforaminal epidurals in 2011, (3) SIJ injections in 2012, and (4) RF of the facet nerves/joints in 2012, the only injection codes for which 77003 can be billed are “regular” (translaminar) epidurals (62310, 62311), along with acute pain epidurals with indwelling catheters (62318, 62319). If you bill 77003 with any code other than those 4 codes, it is incorrect.


5. Speaking of billing the indwelling catheter codes, the CPT Code contains new guidance about a number of issues:


a. The CPT Code states that in order to bill the indwelling catheter codes (62318, 62319), the catheter must remain in place for more than “a single calendar day”; otherwise, you must bill the single injection codes, 62310 or 62311. So, practically, that means if you are administering a chronic pain epidural, using a catheter, and you remove the catheter on the same date you insert it, you cannot bill the higher paying indwelling catheter codes, but are limited to the single injection codes (62310, 62311).


b. Further, the CPT Code explains that even if you manipulate the catheter to multiple levels, you are limited to a single injection code.


c. The CPT Code also states that you determine the region to bill (C/T v. L/S) based on the region into which the catheter is initially inserted, not the level to which the catheter is threaded and not the level to which the contrast, anesthetic, or steroid spreads.


6. The MILD procedure has its own codes now, but they are “T” codes (i.e., emerging technology codes, otherwise known as Category III codes), contained in the back of the CPT Code. If there is a T code available, you must bill it, rather than a Category I code contained in the primary section of the CPT Code. The new MILD procedure codes are 0274T (C/T) and 0275T (lumbar). Both of these codes bundle fluoro and bundle multiple levels in the same region into a single code, i.e., L3, L4, and L5 are billed with a single code, 0275T.


7. Vertebroplasty and kyphoplasty now bundle both bone biopsies and treatment for vertebral fractures (open or closed), so you can only bill the codes for the vertebroplasty or kyphoplasty.


8. The pump analysis, reprogramming, and refill codes have undergone an overhaul. In the past, we typically billed 2 codes for analysis/reprogramming and refills, i.e., 62368 (analysis and reprogramming) and 95990 (nurse refill) or 95991 (doc refill). Now, if you perform all three of those services, you are required to bill one code – a new code for 2012 – 62369 (non-MD service) or 62370 (“requiring physician skill”). What if you analyze and reprogram, but don’t refill? You will continue to use 62368, defined as analysis with reprogramming. What if you analyze and refill, but don’t reprogram? You will bill only one code, 95990 (nurse analysis and refill) or 95991 (doc analysis and refill), since both 95990 and 95991 are redefined to include not just a refill, but to bundle the analysis as well. What if you analyze, reprogram, and refill? Well, that’s the new code 62369 (non-MD) or 62370 (MD).


9. Insofar as stimulators are concerned, there are two primary changes:


a. First, the CPT Code descriptor for stimulator programming (95972) has always contained a time element, i.e., “programming, first hour.” The CPT Code now advises that if the programming lasts 30 minutes or less, you have to append the 52 modifier (i.e., the reduced services modifier). If the programming time reaches 31 minutes, you can bill without the modifier.


b. Second, in order to bill the complex programming code (95972), as opposed to the simple programming code (95971), you have to document 4 or more of the 12 parameters that can be programmed. You might want to create a template with check boxes for each of the 12 parameters and check off which ones were reprogrammed. If there is no documentation of which parameters were programmed, you will be limited to the simple programming code on audit.


10. The 2012 CPT Code confirms that pulsed RF is to be billed as 64999.


11. Finally, the E&M Guidelines in the CPT Code are tweaked to confirm that a new patient is one that hasn’t been seen in 3 years by a physician in your group who is not in your same specialty, AND NOT IN YOUR SAME SUBSPECIALTY. The CPT Code does not define a “subspecialty,” but for Medicare, if you are in an anesthesia group, and you have filed an 855 form showing your subspecialty as interventional pain management, the fact that your anesthesia partners have seen the same patient within 3 years will not preclude you from billing that same patient as a new patient since you are in a different subspecialty. I suspect the rule is even broader than that (i.e., PM&R doc who is referred a patient by his interventional pain partner, specifically for a PM&R issue that the interventional pain doc is not qualified to address, can bill a new patient visit even though the pain doc saw the patient 1 month ago), but that will be something we will probably have to fight about in defending audits.