Are you being needled by P-stim? See our latest coding question from one of our readers.

Question to Healthcare Fraud Shield

I have an outpatient surgery center doing P-Stim (auricular stimulation) for back pain and using CPT 64555 (percutaneous neurostimulator – peripheral nerve).  P-stim is FDA approved for acupuncture and is a small device that can be done in a physician’s office.   My situation is that I have a surgery center billing us (facility claims) and the rendering provider billing (professional claims).  Not much is written about using CPT 64555 for p-stim.  There is apparently an unpublished AMA letter that speaks to it, but no one is able to locate it!  How is using CPT 64555 a misrepresentation here?

Any chance you may have encountered this situation before and could offer some advice?  I need something a bit more solid to build a case on!

-Healthcare Fraud Shield Reader

Answer

This is very interesting.  We watched a quick youtube video on the procedure which we’ve linked here if you haven’t seen it (http://www.youtube.com/watch?v=P_Ro5kxnbgg). You can take a couple different approaches.  First of all, this procedure is not appropriate for an ASC setting.  No anesthesia is required. (I hope you aren’t seeing anesthesia claims as well!)  Check your policies and member’s benefits as they may speak to appropriateness of ASCs for minor procedures.  Secondly, it appears that this would fall under the category of acupuncture with electrical stimulation or possibly experimental/investigational.  It also does not appear to fit the code description of implantation of an electrode.  They are simply placing needles in the ear.  One source we read suggested billing the unlisted code CPT 64999.  Ideally, if your plan could quickly develop a medical policy that would help stop the bleeding.  This looks like a trend we may be seeing a lot of in the future!  Thank you for sharing.

-Healthcare Fraud Shield

Facet Joint Injection Question

Question:
We are investigating a provider who is performing facet joint injections and reporting the services with CPT® codes 64490-64495 (injection paravertebral facet joint- cervical, thoracic or lumbar).  I noticed that the code description includes the language “with image guidance (fluoroscopy or CT).”  Based on a review of the provider’s medical records, fluoroscopy is not used.  When the doctor was questioned, he said that he doesn’t need to use fluoroscopy as he knows he is in the facet joint by palpating the area.  My question is—does he have to perform fluoroscopy to be paid for this code?  If not, what is the correct code?  Thank you for your help.

Answer:
Great question!  In 2010, the AMA changed the CPT® codes and descriptions for facet joint injections.  Prior to this time, the fluoroscopic image guidance was billed separately.  This coding change opened the door for provider misuse of the codes as some practitioners, like the one in your investigation, do not have fluoroscopy equipment in their offices.  According to the CPT® coding instructions listed in the first paragraph in the “Paravertebral Spinal Nerves and Branches” section of the manual, “If imaging is not used, report 20552-20553.”  These codes which describe trigger point injections, have a much lower assigned RVU (relative value unit), therefore, payment is significantly less.  Based on the information you provided and the CPT® coding instructions, it would be appropriate to down-code the reported service to trigger point injections (codes 20552-20553).

Good luck with your investigation!

If you have any comments or questions, please email us at info@hcfraudshield.com.