Melissa Posted Wed 14th of May, 2014 17:56:27 PM
The physician says he did an L5-S1 Epidural Steroid injection and then he did and SI joint block on the RT and LT. He did not use fluoroscopy. How would I code this
SuperCoder Answered Wed 14th of May, 2014 18:19:30 PM
While performing 62311 (Injection(s), of diagnostic or therapeutic substance(s) (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)) together with 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed ) is rare, the Correct Coding Initiative (CCI) edits show that you may unbundle them with a modifier.
If you were to unbundle this pair, you need to append modifier 59 to 62311, because it is the column 2 code (the component code) to the more comprehensive code, 27096.
Note, however, that due to the rarity of these two codes being indicated/performed together, your documentation for proving medical necessity will have to be very clear.
Use Modifier 50 with 27096.
Melissa Posted Wed 14th of May, 2014 20:19:20 PM
Since he did not use fluoroscopy on either procedure, should I use 62311 and 26010?
SuperCoder Answered Thu 15th of May, 2014 17:36:14 PM
In that case Use 62311 and 20552
Please see CPT book. It's there under 27096
(If CT or fluoroscopy imaging is not performed, use 20552)