Myelography Coding Update: Revealing the Consequences of Bundling M Morris(1), R Whiting(2), S Rothenberg(1), B Saboury(1), S Boateng(1), R Tu(2) (3) (1)University of Maryland Medical Center, Baltimore, MD, (2)George Washington University, Washington, DC, (3) Progressive Radiology, Falls Church, VA eEdE-6; 1973

Disclosures No disclosures to report.

Objectives CPT and bundled code creation overview New code changes for myelography Consequences of bundling Cases and quiz questions

CPT and Bundled Code Creation Overview

Current Procedural Terminology (CPT) Code Creation Overview CPT is “medical nomenclature used to report medical procedures and services under public and private health insurance programs.” 1 CPT codes are owned by the American Medical Association (AMA). The CPT Editorial Panel of the AMA meets 3x yearly to create and update codes. CPT Editorial Panel

Bundled Code Creation A bundled CPT code is two or more CPT codes that have been combined into one code. Bundled codes are created when a screening of codes shows two or more procedures occurring together more than 75% of the time. The screening is done by the Relativity Assessment Work Group (RAW) which is a committee of the Relative Update Committee (RUC) of the AMA. 3

New Code Changes for Myelography

Myelography Bundled Codes CPT 2015 introduced four new bundled codes for myelography combining the procedure, supervision and interpretation, ONLY WITH LUMBAR INJECTION APPROACH, cervical injection was unaffected. 2 Relativity Assessment Workgroup (RAW) screens captured lumbar contrast injection with fluoroscopic guidance with myelography occurred more than 75% together. Unbundled codes were retained to capture 2 physicians or other qualified health care providers performing the procedure (e.g. neurosurgeon injecting ) and interpreted by another (e.g. radiologist), and thus coded separately. 4

New 2015 Bundled Myelography Codes Unbundled Codes Lumbar Injection Fluoroscopic Guidance AND Myelography Interpretation: Cervical Thoracic Lumbar Two or more regions 2015 – Four New Bundled Codes Intrathecal contrast administration via lumbar injection AND X-ray myelographic radiologic supervision and interpretation (RS&I): Cervical Thoracic Lumbar Two or more regions

Bundled codes: lumbar injection of intrathecal contrast (no bundling with cervical injection)

Bundled codes for lumbar injection of intrathecal contrast (no bundling with cervical injection) Myelography is defined as plain film imaging of the spine with intrathecal contrast with cervical or lumbar injection. Only lumbar injection of contrast administration followed by cervical, thoracic, lumbar, and 2 or more region x ray imaging was affected by bundling. Cervical injection of contrast and subsequent plain film imaging is unchanged.

Bundled codes for lumbar injection of intrathecal contrast (no bundling with cervical injection) If a single physician injects intrathecal contrast, supervises, interprets and performs a myelogram, the bundled codes are used. Radiologist: Lumbar injection and cervical myelographic RS&I Fluoroscopic guidance and injection are bundled in the code. If the provider who supervised the injection of contrast is different from the radiologist who interprets the myelogram the preexisting codes are used. Neurosurgeon: lumbar injection fluoroscopic guidance Radiologist: cervical myelogram

Modifier Code -59 for CT Spine with Contrast Center for Medicaid and Medicare Services’ (CMS) National Correct Coding Initiative (NCCI) asses proper coding. NCCI was concerned that coding for both spinal CT and myelography on the same patient on the same day was duplicative coding. 4 After subspecialty commentary clarified the validity of using both codes, NCCI recommended using modifier code 59. Modifier code 59 (“distinct procedure or service”) allows two procedures to be coded together that otherwise might be flagged as duplicative.

Using modifier code -59 If a radiologist supervises and interprets a lumbar myelogram and then interprets a lumbar CT scan, he would use modifier code lumbar myelogram, lumbar CT with contrast If separate providers performed the myelogram and lumbar CT, then they each bill without using modifier 59. Radiologist A: lumbar myelogram Radiologist B: lumbar CT with contrast If one provider provides needle injection of contrast under fluoroscopic guidance however no myelogram interpretation was performed, then a lumbar CT scan w/ contrast is interpreted by a radiologist, neither the bundled codes, nor modifier 59 would be used. Provider: lumbar intrathecal injection of contrast + fluoroscopic guidance Radiologist: Lumbar CT

Consequences of Bundling

Bundled Code Valuation When a new bundled code is created, it is assigned a relative value unit (RVU) by the Relative Update Committee (RUC) of the AMA which determines reimbursement. Occasionally unbundled codes will be retained. e.g., if the procedures can be done independently of each other, or if separate providers can do each procedure. Bundled codes can dramatically affect reimbursement. Breast biopsies were bundled in 2013, and reimbursement fell by 22% for ultrasound-guided, 16% for sterotaxis, and 3% for MRI.

Unbundling Errors An “unbundling” error occurs when a provider uses separate CPT codes inappropriately when there is a bundled code available. This can delay reimbursement, or trigger and audit. For example, if a radiologist performs a lumbar injection and myelogram: (In this case, lumbar myelogram includes reimbursement for injection) Unbundling Error: Lumbar Injection Fluoroscopic Guidance Lumbar Myelogram Correct Billing: Bundled Lumbar Myelogram

Nuances to New Codes Bundled codes are used with lumbar injection only. The relatively less common cervical contrast injection require unbundled codes. Bundled codes for cervical injection were not created since they did not meet the 75% RAW threshold. 4

Cases and Quiz Questions

Case #1 Mr. X has worrisome back pain and a CT contrast study of the lumbar spine is ordered. Radiologist Y injects contrast into the lumbar region, takes a CT scan of the patient’s lumbar region, and provides interpretation for the CT. Which of the following should be coded? Lumbar Injection Fluoroscopic Guidance Lumbar Myelogram Bundled Lumbar Myelogram 59-Modifier Distinct Procedure Lumbar CT with Contrast

Case #1 - Explanation The radiologist uses the unbundled codes since myelogram is not ordered. The bundled codes include fluoroscopic guidance, but the unbundled codes do not. Modifier 59 is not used since only one procedure (spinal CT) was performed.

Case #1 - Quiz Question The Radiologist injects contrast media into the lumbar spine. With the needle in place, a few x-rays are obtained. Those images appear in the final study. Should the radiologist instead use the code for Bundled Lumbar Myelogram or add code Lumbar Myelogram? Answer: Neither An x-ray showing needle placement is not a myelogram. A myelogram is a comprehensive evaluation of the spine. Only the CPT codes lumbar spine injection and Fluoroscopic guidance should be used.

Case #2 Ms. Y has upper back pain and a myelogram is ordered along with a CT scan with contrast. Radiologist Y injects contrast into the lumbar region, performs and interprets a myelogram, but then is called away. Then radiologist Z takes over and takes a CT scan of the patient’s spine, and provides interpretation. Which of the following should be coded? Lumbar Injection Fluoroscopic Guidance Thoracic Myelogram Bundled Thoracic Myelogram 59-Modifier Distinct Procedure Thoracic CT with Contrast Radiologist Y Radiologist Z

Case #2 - Explanation Radiologist Y uses the bundled code for thoracic myelogram. He uses this code because he injects with fluoroscopic guidance and supervises and interprets a myelogram on the same patient on the same day. Radiologist Z uses the code for CT scan with contrast, thoracic region.

Case #2 - Quiz Question The Radiologist performs a myelogram of the thoracic region. She uses fluoroscopic guidance in order to place the needle in the correct location. Why does the radiologist not bill for Fluoroscopic Guidance? Answer: Fluoroscopic guidance is included in the new bundled code thoracic myelography.

Case #3 Ms. A has cervical back pain and a spine study is ordered. Radiologist Y injects contrast into the lumbar region, performs a myelogram, CT scan and provides interpretation for all images. Which of the following should be coded? Lumbar Injection Fluoroscopic Guidance Cervical Myelogram Bundled Cervical Myelogram 59-Modifier Distinct Procedure Cervical CT with Contrast

Case #3 - Explanation The radiologist codes for the bundled cervical myelography procedure which includes injection and fluoroscopic guidance. He also codes for the cervical CT procedure. However, since both procedures were done, modifier 59 is added which signals that both procedures are distinctly separate.

Case #3 - Explanation CODING TIP: If the injection was via a C1-C2 injection and not lumbar injection then always use a NON BUNDLED cervical injection, fluoroscopic guidance and cervical myelogram codes.

Case #3 - Quiz Question Radiologist Y performs a bundled thoracic myelogram and bills for it, and on the same day with the same patient radiologist Z performs a thoracic CT with contrast. Does the radiologist Z add modifier code 59 because two procedures were done? Answer: No. The modifier is used when both procedures are done by the same provider on the same patient on the same day.

Conclusion CPT codes are created and maintained CPT Editorial Board of the AMA. Four new myelography bundled codes were created because procedures occurred more than 75% together. Bundled codes can reduce reimbursement and if billed incorrectly, could trigger an audit for “unbundling.” If one provider is providing both injection and myelography, use the bundled code. If in addition to a myelogram, a CT is obtained, add code modifier 59, distinct procedure.

References 1.Coding with CPT® for Proper Reimbursement. American Medical Association. practice/coding-billing-insurance/cpt.page?. Accessed April 25, practice/coding-billing-insurance/cpt.page? 2.CPT 2015 Professional Edition. American Medical Association. assn.org/store/catalog/productDetail.jsp? product_id=prod &navAction=push. Accessed April 25, assn.org/store/catalog/productDetail.jsp? product_id=prod &navAction=push 3.Hirsch JA, Silva E 3rd, Nicola GN, et al. The RUC: a primer for neurointerventionalists. J Neurointerv Surg 2014;6:61–64. 4.Chokshi, F. H., Tu, R. K., Nicola, G. N., & Hirsch, J. A. Myelography CPT Coding Updates: Effects of 4 New Codes and Unintended Consequences. AJNR Am J Neuroradiol originally published online on January 7, 2016, /ajnr.A Lotfipour, A. Breast Biopsy Current Procedural Terminology Code Bundling and the Impact on Reimbursement. Journal of the American College of Radiology, 12(1),