When is Modifier -59 Appropriate for use with CPT 62311 & Other Pain Procedures on same DOS?

Understand When Modifier -59 is Appropriate for Use With 62311 (Lumbar Epidural) and Other Pain Procedures

By Rob Kurtz | July 29, 2010

Tags: 62311 | ASC coding | G0260 | Medi-Corp | modifier 59

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Q: When our pain doc does 62311 (lumbar epidural) with G0260 (SI joint injection), I looked at CCI and it says 62311 is bundled; however, you can use a modifier to differentiate between services, and to modify 62311. What documentation would I use to justify this -59?

Leslie Johnson, CCS-P, CPC, Director of Coding and Education, Medi-Corp. I've actually been doing research on this subject and have found two separate reasons that are acceptable to payors and to Medicare for why/when a modifier -59 is appropriate to use on the 62311 when done at the same encounter as the G0260.

There needs to be a distinct reason for doing both procedures. It's fact that some medial branches innervate the sacral area, so they will do a medial branch block with an sacroiliac (SI) joint injections to treat the same kind of pain. Ditto for when they might do a caudal epidural steroid injection (ESI) and an SI joint pain injection. This is a "double whammy" for the same problem so we need to be careful and look at where they're injecting, and the reason for the injection. In those cases I mentioned above, you would only code for the SI joint injection because the other two types of injections are for similar reasons, and are considered inclusive.

Where the needle actually goes and the intent of the procedure will determine whether or not modifier -59 should be on the inclusive code. I've found, in the "utilization" information found in the policies, that some payors specifically state that if, in the course of treating one problem, a new one comes up or new symptoms pop up, then it may be appropriate to code out both procedures and get paid for both. This should be evident in the documentation.

Example: Patient comes in with low back pain, an ESI was ordered with a follow-up in 10 days. During this follow-up period, the low back pain eases, but a new symptom emerges — pain that could be pelvic or lower than the original low back pain.

So on the next visit, the physician may decide to do an ESI to treat the low back pain, and the SI joint injection to treat the low-low back or sacral region pain. Same diagnosis, but for different reasons. Documentation should show this, and you should be able to win an appeal and/or be justified in using modifier -59 based on this kind of documentation when you bill 62311-59 and the G0260.

The second reason — and I was a bit shocked by this one — is for why they might do multiple injections. In the utilization information, payors (especially Medicare) state that "it's not expected that an ESI would be performed in conjunction with SI joint injection, trigger point, selective nerve root blocks" etc. Again, different modalities appear to be used to treat the same issue.  It may actually be so, but there may be other reasons that the docs may be thinking but aren't documenting.

For the rest of this article, please see Becker's ASC Review online