Caudal ESI

[painfre]

While I was doing my PMR residency, I did some caudals with a 25 g Quincke needle and inject about 10 ml of LA and steroid . During my fellowship at one hospital we used a Epimed catheter and injecting about total of about 15ml and bill as caudal ESI.
while in other hosp which is a VA we used to take consent as Modified racz procedure and inject about 16 ml using catheter one time.

If I am doing inj one time with epimed catheter should I code as Caudal ESI or racz or percutaneous adhesionolysis. There is no option for caudal ESI with catheter at our VA hosp

Thanks

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[lobelsteve]

62311 and eat the catheter cost.
Catheter's are not more than $18 each from Arrow.

 

[painchas]

22q single shot and advance the needle up the hiatus until you see sufficient spread at the L5 level. If much higher is needed then you need another technique. Why the catheter? Most failed backs will give other options if you need to be higher in the space. Why do you want to incur the cost of the catheter for the meager medicare reimbursement

 

[drpainfree]

if you are using racz catheter, can you bill as percutaneous epidural adhesiolysis, 62264?

 

[clubdeac]

if you are using racz catheter, can you bill as percutaneous epidural adhesiolysis, 62264?

technically only if you actually do some adhesiolysis though, you can't just thread it up to L5-S1 and shoot in some steroid and anesthetic and call it an adehesiolysis. Well you can but... you'll go to hell jk

 

[lobelsteve]

I do not bill for adhesiolysis even when I do adhesiolysis. I do not think it is a billable/reimbursible code. I just call it a caudal with catheter, and I will be the catheter code if I drag and drop medications at multiple levels. But if just reaching a single target it is better to eat the cath cost. I believe there is a slippery slope in catheter billing- some folks would have you use the catheter on multiple days, others at multiple times in one day, others at multiple levels on same day. My understanding is that the cath code is acceptable when doing it to perform procedures at multiple levels without having to perform multiple transforaminals at the same time of service. A great cost savings to the system can be realized with a drag and drop technique over 3 level TFESI.

 

[lonelobo]

From Joanne Mehmert(pain billing/coding expert), only time you can bill catheter charge for epidural is when it is Indwelling

 

[lobelsteve]

From Joanne Mehmert(pain billing/coding expert), only time you can bill catheter charge for epidural is when it is Indwelling

Define indwelling. 5 minutes, 5 days?

 

[mdvol]

Lobelsteve which arrow catheter do you use?

 

[lonelobo]

Define indwelling. 5 minutes, 5 days?

She stated this was for hospital pts or pts who return to your clinic next day
for lysis of adhesions.

David Vaughn JD, also went over this at billing seminar and recommended
not use coding for cath in outpatient setting- as this has come under significant problems with audits

 

[lobelsteve]

Lobelsteve which arrow catheter do you use?

Arrow EC-05000

and I do cath cases rarely (every 1-2 weeks) so I think if I'm not exactly appropriate, I am under the radar and following the definition in the CPT book to the letter.

 

[TX PAIN DOC]

22q single shot and advance the needle up the hiatus until you see sufficient spread at the L5 level. If much higher is needed then you need another technique. Why the catheter? Most failed backs will give other options if you need to be higher in the space. Why do you want to incur the cost of the catheter for the meager medicare reimbursement

Just be careful how far you advance the needle because the thecal sack lies around S2-S3. The inferior edge of the SI joints are good landmarks not to pass with the needle if you can't see the sacral foramens.

RACZ procedure reimbursement includes the cost of the catheter. Billing a 2 to 3 level transforaminal injections when placing a catheter via the sacral hiatus helps with the cost of the catheter and cuts down on the complication risks. I document images showing each nerve root level. However, be careful on failed backs, spinal stenosis, or epidural adhesions. Always stop if there is resistance and be generous with contrast. I have seen catheters be intra-thecal or even show a vascular pattern!

 

[drf]

What are you guys doing for landmarks/fluoro to decide you are in far enough? I usually just shove it in then pass the catheter. Been using Epimed introducer kit lately with their radioopaque catheter. However, in fellowship I think I remember using a LOR technique.

Any point to do LOR? So far my success rate in getting appropriate contrast spread is 100% by just shoving it in until it doesn't want to go anymore, pulling needle and stylette out, then passing catheter through angiocath.

 

[lobelsteve]

Palpate cornu. Forget it.
Use lateral fluoro to see SC junction. 27G on skn, 25G to ligament.
18G to ligament and through it not more than 1cm. shoot 1cc contrast to verify epidural spread. The LOR is readily obtained without a syringe on the styletted needle. Lateral fluoro also readily identifies the crossing o the ligament (as long as you enter in the midline). Thread cath to targets.

 

[Jcm800]

Just be careful how far you advance the needle because the thecal sack lies around S2-S3. The inferior edge of the SI joints are good landmarks not to pass with the needle if you can't see the sacral foramens.

RACZ procedure reimbursement includes the cost of the catheter. Billing a 2 to 3 level transforaminal injections when placing a catheter via the sacral hiatus helps with the cost of the catheter and cuts down on the complication risks. I document images showing each nerve root level. However, be careful on failed backs, spinal stenosis, or epidural adhesions. Always stop if there is resistance and be generous with contrast. I have seen catheters be intra-thecal or even show a vascular pattern!

what are you talking about?

are you doing a Racz procedure, AND doing TFESI? are are you calling the nerve root visualiziation a TFESI from the caudal approach, just because you are using a Racz catheter.


if you go through the hiatus and put a catheter up there, how can you bill TFESI...unless im mistaking what you are saying, that sounds fishy

 

[Jcm800]

Just be careful how far you advance the needle because the thecal sack lies around S2-S3. The inferior edge of the SI joints are good landmarks not to pass with the needle if you can't see the sacral foramens.

RACZ procedure reimbursement includes the cost of the catheter. Billing a 2 to 3 level transforaminal injections when placing a catheter via the sacral hiatus helps with the cost of the catheter and cuts down on the complication risks. I document images showing each nerve root level. However, be careful on failed backs, spinal stenosis, or epidural adhesions. Always stop if there is resistance and be generous with contrast. I have seen catheters be intra-thecal or even show a vascular pattern!

what are you talking about?

are you doing a Racz procedure, AND doing TFESI? are are you calling the nerve root visualiziation a TFESI from the caudal approach, just because you are using a Racz catheter.

"Billing a 2 to 3 level transforaminal injections when placing a catheter via the sacral hiatus helps with the cost of the catheter and cuts down on the complication risks. I document images showing each nerve root level. "
how exactly does billing a 2-3 level TFESI decrease the complication risks?

if you go through the hiatus and put a catheter up there, how can you bill TFESI...unless im mistaking what you are saying, that sounds fishy

 

[lobelsteve]

what are you talking about?

are you doing a Racz procedure, AND doing TFESI? are are you calling the nerve root visualiziation a TFESI from the caudal approach, just because you are using a Racz catheter.

"Billing a 2 to 3 level transforaminal injections when placing a catheter via the sacral hiatus helps with the cost of the catheter and cuts down on the complication risks. I document images showing each nerve root level. "
how exactly does billing a 2-3 level TFESI decrease the complication risks?

if you go through the hiatus and put a catheter up there, how can you bill TFESI...unless im mistaking what you are saying, that sounds fishy

Not fishy- lying. Yes, AMP I know your lurking and want to strike about my drag and drop. Read the CPT book.

 

[hyperalgesia]

Just be careful how far you advance the needle because the thecal sack lies around S2-S3. The inferior edge of the SI joints are good landmarks not to pass with the needle if you can't see the sacral foramens.

RACZ procedure reimbursement includes the cost of the catheter. Billing a 2 to 3 level transforaminal injections when placing a catheter via the sacral hiatus helps with the cost of the catheter and cuts down on the complication risks. I document images showing each nerve root level. However, be careful on failed backs, spinal stenosis, or epidural adhesions. Always stop if there is resistance and be generous with contrast. I have seen catheters be intra-thecal or even show a vascular pattern!

Documenting contrast spread at each NR level is an epidurogram, not multiple TFESIs.

 

[TX PAIN DOC]

what are you talking about?

are you doing a Racz procedure, AND doing TFESI? are are you calling the nerve root visualiziation a TFESI from the caudal approach, just because you are using a Racz catheter.


if you go through the hiatus and put a catheter up there, how can you bill TFESI...unless im mistaking what you are saying, that sounds fishy

No, sorry for the confusion. You would never bill for a RACZ procedure and a TFESI! I was just making the point not to bill for the epidural catheter placement/ management when using the lysis of adhesions code.

As for performing a TFESI/SNRB when using a catheter placed through the sacral hiatus and threaded to a nerve root level instead of a needle placed through the neuroforamen, I welcome everyone's input. Both approaches can accomplish the same treatment at the nerve root, or am I mistaken?

It's my first year in practice and I am going by the coding done in the group and by other pain doctors. I would appreciate any help to avoid any coding mistakes, thanks.

 

[Jcm800]

[
As for performing a TFESI/SNRB when using a catheter placed through the sacral hiatus and threaded to a nerve root level instead of a needle placed through the neuroforamen, I welcome everyone's input. Both approaches can accomplish the same treatment at the nerve root, or am I mistaken?

you are mistaken.

if you wanna bill for TFESI, then go from the skin into the foramen, the way its coded and suppose to be...that is a TFESI, you can't bill a TFESI going through the caudal approach.

going through the sacral hiatus is a caudal ESI, regardless of where you direct the catheter...
only other option is epidural LOA, which requires LOA...and fluoro is bundled.

 

[hyperalgesia]

As for performing a TFESI/SNRB when using a catheter placed through the sacral hiatus and threaded to a nerve root level instead of a needle placed through the neuroforamen, I welcome everyone's input. Both approaches can accomplish the same treatment at the nerve root, or am I mistaken?

With that logic, you could forget the catheter and just do a caudal with a hypodermic and code for 3 bilateral TFESIs... Why would anyone bill for a LESI when each NR can be billed separately with enough contrast? Our procedures are billed based on technique/approach. If you get audited billing like you are, Medicare will fry your whole group for fraud. I'm sorry to hear you are in this situation. Your partners will either thank you or hate you for telling them. But I have secretly always wanted to be a whistleblower...

 

[clubdeac]

Isn't it sad that insurance companies have led us to have coding debates. We should be more concerned with taking care of patients than how to bill what we do. Not to blame us but rather the damn insurance companies. If we don't play their little game just right, we get fried. What a bunch of bullsh*t. My belligerence with illogical authority is coming out. Always was a problem maker, even in residency

 

[Sandpaper]

Nothing sad about it club. Doing a caudal and billing for TFESIs is fraud. More people doing that and there goes the goose that laid the golden egg. And more, taking care of patient entails billing correctly and getting paid for what you do. It's this kind of fraudulent sh it that gives all of us a bad name - that and billing for epidurogram on every ESIs.

 

[Ligament]

Keep in mind that it is the insurance companies and the AMA with their codes that is causing all this cognitive dissonance amongst us. They are the real evil here.

 

[clubdeac]

Nothing sad about it club. Doing a caudal and billing for TFESIs is fraud. More people doing that and there goes the goose that laid the golden egg. And more, taking care of patient entails billing correctly and getting paid for what you do. It's this kind of fraudulent sh it that gives all of us a bad name - that and billing for epidurogram on every ESIs.

Well I agree 100%, in addition to being flat out unethical, guys who bill fraudulently ruin it for the rest of us and drive up health care costs. But I will say, most doc's who fall prey to such unethical behavior do so b/c they've been watching their bottom line decrease yearly. It's gotta be frustrating I imagine. Why is my dad getting reimbursed less now than he did in 1990? I call bullsh*t. But ligament is right, the AMA and insurance companies are to blame for our discord

 

[TX PAIN DOC]

With that logic, you could forget the catheter and just do a caudal with a hypodermic and code for 3 bilateral TFESIs... Why would anyone bill for a LESI when each NR can be billed separately with enough contrast? Our procedures are billed based on technique/approach. If you get audited billing like you are, Medicare will fry your whole group for fraud. I'm sorry to hear you are in this situation. Your partners will either thank you or hate you for telling them. But I have secretly always wanted to be a whistleblower...

Thanks a million. Glad this forum is around.

I discussed this with my group and they had a talk with the billing company. They were apparently unaware. In the end, the billing company is making the needed changes and refunds. Needless to say, the group plans to do a self audit now.

I plan to keep an eye on all my billing from here on out and not rely solely on coders. In the end, I am at fault in the eyes of medicare when there is an error by the billing company.