# peripheral nerve block



## Jcelin (Oct 30, 2013)

PROCEDURE: Integrated nerve block

Posterior tibial nerve was blocked
Saphenous nerve was blocked
Sural nerve was blocked

Same procedure was performed on both left and right ankle.

I reported as 64450 59 LT 51 with quantity of 3 same on RT, but the payer denies and says its experimental. Any ideas please... on how to bill the 3 procedures


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## MarcusM (Oct 30, 2013)

Check Medicare LCD and make sure the dx code is appropriate


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## Jcelin (Oct 30, 2013)

Dx code are 729.5 and 719.47....


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## dwaldman (Oct 30, 2013)

I would not add  modifier 59 and 51 together. Nor would I add the 59 and 51 and bill it with quantity on one line. I am not sure that is what was done but I was having trouble determining that.

Possiblly

64450 RT quantity 3 with additional note stating 3 separate injections performed 

or

64450 RT
64450 51 RT quantity 2 with additional note stating 3 separate injections performed.

Additionally might want confirm they don't have LCD or medical policy like the one below

Coverage Guidance

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.

At present, the literature and scientific evidence supporting the use of peripheral nerve blocks or injections in multiple neuropathies or underlying systemic diseases that are producing peripheral neuropathies, especially for the Medicare population, is insufficient to warrant coverage. These procedures are considered investigational, and are not eligible for coverage for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases. 



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   Coding Information Bill Type Codes: 
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 

N/A 

Revenue Codes: 
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.


N/A 

CPT/HCPCS Codes 
Group 1 Paragraph: N/A

Group 1 Codes:
 64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 


ICD-9 Codes that Support Medical Necessity 
Group 1 Paragraph: Note: ICD-9 codes must be coded to the highest level of specificity.

Group 1 Codes:
XX000 Not Applicable 


ICD-9 Codes that DO NOT Support Medical Necessity 
Paragraph: N/A

Codes: 
249.60 - 249.61 opens in new window  SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED - SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, UNCONTROLLED 
250.60 - 250.63 opens in new window  DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED 
354.5  MONONEURITIS MULTIPLEX 
355.8  MONONEURITIS OF LOWER LIMB UNSPECIFIED 
355.9  MONONEURITIS OF UNSPECIFIED SITE 
356.0 - 356.9 opens in new window  HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY 
357.0 - 357.9 opens in new window  ACUTE INFECTIVE POLYNEURITIS - UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES 
719.47  PAIN IN JOINT INVOLVING ANKLE AND FOOT 
729.2  NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED 
782.0  DISTURBANCE OF SKIN SENSATION 



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   General Information 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 of the patient.


3.The submitted medical record should support the use of the selected ICD-9-CM 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.

A peripheral nerve injection may be allowed during the reconsideration process if the medical record supports a medically necessary service. 
Sources of Information and Basis for Decision 
V. Bril, J. England, G.M. Franklin, et al. Evidence-based guideline: Treatment of painful diabetic neuropathy : Neurology 2011;76;1758; Published online before print April 11, 2011.

Chaudhry V, Stevens JC, et al. Practice advisory: utility of surgical decompression for treatment of diabetic neuropathy: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2006;2:1805-1808.

Odell RH, Sorgnard R, New technique combines electrical and local anesthetic for pain management:
Practical Pain Management; June 2011: online at http://www.practicalpainmanagement.com/issue/1106

Cernak C, Marriot E, et al. Electrical current and local anesthetic combination successfully treats pain associated with diabetic neuropathy: Practical Pain Management; April 2012 online at:
http://www.practicalpainmanagement.com/issue/1203


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