# Popliteal and saphenous nerve blocks



## vanessa10

I have a chart where the Dr is doing a single popliteal nerve block and a saphenous nerve block. the coder that codes this site is telliing me that both codes get 64450. I do not agree. Can someone tell me where i can find something in writing saying this is incorrect and showing the correct codes to use??


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## dsmith1979

http://www.usra.ca/sb_sciaticpopliteal 
That website tells you that the popliteal region is the sciatic nerve. 
For the poplital block we use 64445 and for the saphenous block we use 64450.
I hope this helps!
Denise


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## vanessa10

one of my other co workers is telling me to use 64447 for the saphenous block. Does anyone know anything about that?


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## cmcgarry

The saphenous nerve is a deep branch of the femoral nerve; therefore, 64447 is correct.


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## JBSAX

*Popliteal and Saphenous Nerve Blocks*

I agree with the individual above with the 64445 and 64447 codes.  I have experience coding and billing for anesthesia and pain management dealing with post-operative and long-term pain management.


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## vanessa10

Well thank you to all of you. You have been extreamly helpful!


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## dwaldman

The lateral cutaneous nerve is a branch of iliohypogastric nerve but if the doctor blocked the lateral cutaneous nerve you wouldn't billed based on the nerve it branches from. You would bill 64450 not 64425.

http://www.chiro.org/ChiroZine/FULL/Paresthesias_files/mckfig3.jpg

I believe that by blocking femoral and the sciatic nerves you are targeting pain in the top of the thigh and the knee for the femoral. The sides and back of the calves with the sciactic nerves. The inner calves with the saphenous. I was under the impression that if you look at 64447  or 64445 it does not say femoral nerve  or sciatic nerve and associating branches. If they say the blocked the femoral nerve or the scaitic nerve then I would use those codes but if they are referring to nerves that are not listed in the code range 64400-64449 then I use 64450. This is my own personal preference of trying to accurately reflect what is in the descriptor of the code.


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## dwaldman

per Encoder 64445 reimburses at 71.67 with an RVU of 2.15. 64447 reimburses at 62.21 with an RVU of 1.84, and 64450 reimburses at 62.85 with an RVU  of 1.86. For the popiliteal nerve block, if the actual nerve blocked is a branch of the sciatic nerve and if this would be considered an "other pepherial branch" but you are billing 64445, you would be getting higher reimbursement. The question you would want to ask if it does not mention in the descriptor and associating branches like 64400 then are you allowed to bill the major nerve code and get the higher reimbursement.


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## marvelh

Anatomically there is no popliteal nerve.  The sciatic nerve separates just above the popliteal fossa into the common peroneal nerve and the tibial nerve.  You need to verify with the physician which specific nerve was injected.  

The saphenous nerve, as indicated in another post, is a distal branch of the femoral nerve.  The saphenous nerve can be injected at the patient's ankle which would be quite different from a femoral nerve injection in the groin.

Codes are based on the physician work, risk and practice expense associated with performing the service.  Injecting the main nerve is much different in terms of physician work and malpractice risk than injecting a distal branch.  For example, injecting the medial cutaneous nerve of the leg, a branch of the saphenous nerve which is a branch of the femoral nerve takes less physician work / expertise and carries much less risk than inserting a needle into the patient's groin area which has large arteries, veins and other nerves in close proximity.  

With this in mind, the physician should be injecting the specific nerve, i.e. sciatic or femoral and not a distal branch in order to code the injection for that specific nerve.  If the distal branch does not have a specific injection code and it is likewise a somatic nerve, then it would be appropriate to code the distal nerve injection with 64450.


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## kgurney

What if the provider states they are using the popliteal approach, but they are injecting into the sciatic nerve area just before it branches into the two major components (tibial and common peroneal nerves).  Is this 64445 or 64450??


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## dwaldman

I would have the doctor specifiy which nerve that he is blocking since the descriptor says sciatic nerve for 64445, you want the procedure note to match the code that you are billing. We have a doctor that goes to the outyling facilities and performs sciatic, femoral, common peroneal, and sural nerve blocks. If the documentation states a nerve that matches a code that refers to the nerve in the descriptor of the code than I used the code if there is not a code that mentions the nerve he is blocking I use 64450. In the situation you are describing it is like an either or situation. I would tell the physician I have to be able to choose between 64445 or 64450. Ask which would better describe what he is  targeting-- the main sciatic branch or a other peripheral branch. Sometimes the further explanation from the physician who performed can clarify the code selection and if it requires for him to better describe this in the procedure note for the payer to understand you might need for him to add to the note. I am not familiar with this approach to be able to say this is more describe better with one code rather than another.   I would stick with the concept if the nerve blocked is described in the descriptor than use that code but just because a nerve is a branch of another nerve I would not use the main nerve code just because the nerve that was blocked is branch of a nerve which a code is set up for.


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## marvelh

If the injection is above the sciatic nerve division into the posterior tibial and peroneal nerve, then it would be appropriate to code it as a sciatic nerve injection or 64445


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## dwaldman

"The popliteal nerve block is a block of the sciatic nerve in the popliteal fossa with the patient in the prone position."

"It is the site where the sciatic nerve splits into its two major components,
the tibial and common peroneal nerves (Figure 20-1). To avoid an incomplete nerve block, the needle entry site must be proximal to the splitting of these two nerves (Figure 20-2). Studies have demonstrated that the needle
entry point should be 10 cm from the popliteal crease to optimize needle placement."

http://www.arapmi.org/maraa-book-project/Chapt20.pdf

This link and many others I saw on the internet refer to this approach as blocking the sciatic nerve. If the documentation is unclear that he blocked the sciatic nerve before it branches out. I would ask the physician to clarify that the sciatic nerve is indeed the nerve he blocked.


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## Estherrani

vanessa10 said:


> I have a chart where the Dr is doing a single popliteal nerve block and a saphenous nerve block. the coder that codes this site is telliing me that both codes get 64450. I do not agree. Can someone tell me where i can find something in writing saying this is incorrect and showing the correct codes to use??





vanessa10 said:


> I have a chart where the Dr is doing a single popliteal nerve block and a saphenous nerve block. the coder that codes this site is telliing me that both codes get 64450. I do not agree. Can someone tell me where i can find something in writing saying this is incorrect and showing the correct codes to use??


64447


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## dwaldman

Here are couple of references that I think are useful. 


https://www.anesthesiallc.com/publi...procedure note,(other peripheral nerve block).

A “popliteal” block procedure note, without a description of the anatomy is not helpful in determining the correct code to report. A “popliteal fossa” injection is reported with CPT code 64445 (sciatic nerve), whereas a “saphenous popliteal” is reported with CPT code 64450 (other peripheral nerve block).









						Nerve Blocks for Acute Pain Management: The Main Coding Challenge - Medac
					

The use of nerve blocks for acute pain management has undergone a dramatic transformation over the past ten years.  Not only has the number of blocks performed by our clients...




					www.medac.com
				




Nerve Blocks For Acute Pain Management: The Main Coding Challenge​ Three main codes have generally served the needs of most providers.  They are 64415 for interscalene blocks, 64447 for femoral nerve blocks and 64445 for sciatic block—all of which are paid from a surgical fee schedule and not ASA units, as would be the case for anesthesia services.  There are a number of variations on the theme that have been sanctioned by CPT, the definitive coding reference guide. For example, adductor canal blocks are billed as femoral blocks and popliteal blocks are billed as sciatic blocks.


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