# Genicular nerve, diagnostic, injection - Medicare patient



## nan.coder (Mar 3, 2017)

Hello out there, 

Who have experience in getting paid by Medicare on 64450, diagnostic knee genicular nerve injection for pain?

Need some tips!!

Nancy Boyle, CPC
AAPC St Louis West Chapter


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## dwaldman (Mar 5, 2017)

Two things to consider:
1. Both CMS/NCCI & the AMA state that although multiple injections can be performed when targeting the genicular nerve, only one unit of service should be reported with CPT 64450.
2. Need to confirm if the Medicare carrier you are billing has LCD for CPT 64450. If so this could require documentation and appeal to support the injection was not to treat underlying systemic diseases.
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CMS NCCI Policy Manual 2017

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

Chapter 8 
(2) If a physician injects the superior medial and lateral branches and inferior medial branches of the left genicular nerve, only one UOS of CPT code 64450 (Injection, anesthetic agent; other peripheral nerve or branch) may be reported regardless of the number of injections needed to block this nerve and its branches. 
______________________________________________________________________________________________
AMA CPT Assistant November 2015
Surgery: Nervous System
Question: When a physician injects the superior medial and lateral branches and inferior medial branches of the left genicular nerve, is code 64450 reported three times or just once for the left genicular nerve?

Answer: It is appropriate to report code 64450, Injection, anesthetic agent; other peripheral nerve or branch, for the genicular nerve block of three branches of this nerve around the knee joint; however, code 64450 is reported just once during a session when performing the injection(s). Although one, two, or more injections may be required during the session, the code is reported only once, irrespective of the number of injections needed to block this nerve
and its branches.
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https://www.cms.gov/medicare-covera...35222&ver=6&DocID=L35222&bc=gAAAAAgACAAAAA==?

Local Coverage Determination (LCD):  
Nerve Blocks for Peripheral Neuropathy (L35222)
Coverage Indications, Limitations, and/or Medical Necessity

Nerve blocks cause the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks by the injection of local anesthetic solutions. 

The use of nerve blocks or injections for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically necessary. Medical management using systemic medications is clinically indicated for the treatment of these conditions.

 Limitations

The use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary. 

At present, the literature and scientific evidence supporting the use of peripheral nerve blocks with or without the use of electrostimulation/electromagnetic stimulation, and the use of electrostimulation/ electromagnetic stimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases, is insufficient to warrant coverage. These procedures are considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases.

The use of ultrasound guidance in conjunction with these non -covered injections is also considered not medically necessary and will result in denial.

Subcutaneous injections do not involve the structures described by CPT code 64450, direct injection into other peripheral nerves, but rather the injection of tissue surrounding a specific focus. These therapies are not to be coded using CPT code 64450. This code addresses the additional work of an injection of an anesthetic agent (nerve block), into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas.


Group 1 Codes:

64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 

Associated Information 
Documentation Requirements
1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request. 
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.

Utilization Guidelines
Treatment protocols utilizing multiple injections per day on multiple days per week for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases are not considered medically necessary.

Peripheral nerve injections will not be allowed unless medical records are reviewed and the services are approved during the redetermination process.


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## Jo Burt (Jan 15, 2018)

*64450*

Medicare is paying my claims for the 64450 with the dx M25.56x and M17.1x.  But United Healthcare is not paying with those diagnosis.  Im in Texas and use the LCD L35107, and all I see are diagnosis not payable for the 64450, which the two codes i bill to medicare are on that list. So what dx codes are you using to bill with the 64450.  I am only billing 1 unit not 3.  Any help in this would be greatly appreciated.

Jo Russell, CPC


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## dwaldman (Jan 17, 2018)

I am also billing M17.1X for the last one the physician did with the one unit only for 64450. But it was not United Health Care. They might be confused with osteoarthritis with a injection of nerve for non-post op pain. Might need to write a letter explaining the purpose of the procedure.


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