# Post Operative Pain Nerve Blocks



## lcole7465 (Sep 8, 2015)

I'm searching for a good source to present to my current employer to correct some CPT codes that are being used for some peripheral nerve blocks for post op pain management.

I have looked on a couple, but have not been able to find anything definitive to present. The doctors are coding some peripheral nerve blocks the same as the actual nerve such as the Sciatic and the popliteal nerves are both being coded as 64445/64446. I have always coded this code as 64450.

Any suggestions would be very helpful.

Thank you


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## dwaldman (Sep 8, 2015)

64445  
Injection, anesthetic agent; sciatic nerve, single  

The above states sciatic nerve, it does not allow branch of the sciatic nerve in its code descriptor. 

If a "other" peripheral branch is being blocked then CPT 64450. Although I am not aware of AMA CPT Assistant describing this, I believe you could copy the section of nerve blocks out of the CPT manual and discuss this matter with them. Maybe someone else knows of a published reference regarding this.

Below is the from AMA CPT Assistant where they describe using 64445, they only references it use for the target of the sciatic nerve not other peripheral branches (they also list 64415 & 64447 in the article:


__________________________________________
2004 AMA CPT Assistant 
Sciatic Nerve

Let us now turn our attention to the codes for an injection of an anesthetic agent to the sciatic nerve. 

 64445Injection, anesthetic agent; sciatic nerve, single

 64446Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter, (including catheter placement) including daily management for anesthetic agent administration

Before code 64445 was revised in 2003, it did not identify the number of injections (blocks) of the sciatic nerve. As a result of the revision, code 64445 now refers to a single injection (block) of the sciatic nerve. Code 64445 does cover the sciatic nerve blocks that are used for immediate post-operative pain control and occasionally for ischemic conditions, reflex sympathetic dystrophy (chronic regional pain syndrome), or other painful conditions of the lower extremity. 

Brachial Plexus

Let us first look at the two codes for an injection of an anesthetic agent, often referred to as a nerve block, to the brachial plexus. They are as follows: 

 64415Injection, anesthetic agent; brachial plexus, single

 64416Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration

Code 64415 was revised in CPT 2003 to describe the procedure more clearly. Prior to the revision, the code descriptor did not identify the number of injections of the brachial plexus but rather simply stated, Injection, anesthetic agent; brachial plexus. Code 64415 refers to only a single injection (block) of the brachial plexus. Additionally, code 64415 does cover the majority of brachial plexus blocks that are used for anesthesia for surgery or occasionally for treatment of reflex sympathetic dystrophy (chronic regional pain syndrome) or other painful conditions of the upper extremity


emoral Nerve

The last two nerve block injection codes we will review are specific to the femoral nerve and were added in CPT 2003: 

 64447Injection, anesthetic agent; femoral nerve, single

 64448Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration

Code 64447 is reported for a single nerve block injection, while code 64448 is reported for continuous administration of local anesthetic via a catheter for postoperative pain control and/or chemical sympathectomy. Such continuous procedures are used to provide pain relief, a reversible sympathectomy or increased blood supply to the lower extremity for several days. Additionally, this continuous procedure may be used for ischemia of the lower extremity, postsurgical pain relief, and occasionally for reflex sympathetic dystrophy and chronic pain. However, the primary use of this procedure is for postoperative pain control after surgery on the leg and knee, particularly after total knee arthroplasty. 

To obtain a better understanding of the femoral nerve blocks, we will take a closer look at the intra-service work associated with codes 64447 and 64448. 

Code 64447

Informed consent is obtained preoperatively. In the postanesthesia recovery room or in the operating room prior to general anesthesia, the patient?s right groin is prepped with a betadine solution and a 22-gauge, short-bevel 4-cm needle is inserted approximately 1 cm lateral to the femoral artery and 1 cm caudad from the inguinal ligament after anesthetizing the skin with a small amount of local anesthetic. The proper location of the needle is ascertained with the use of a nerve stimulator, the elicitation of paresthesias, the loss of resistance technique, or with a field block technique. Next, between 15 and 30 ml of local anesthetic is injected carefully and with frequent aspiration to avoid the possibility of intravascular injection. The density and function of the block is then assessed. Onset of block may take 30-40 minutes. Postoperative analgesia typically lasts 12-24 hours. 

The complications of a femoral nerve block include possible infection, injury to the femoral artery with hematoma formation, systemic local anesthetic toxicity, and nerve injury. Persistent quadriceps weakness may suggest neural injury. Fortunately, these complications are rare.


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