# SPG block using Sphenocath



## vkratzer (Feb 2, 2016)

Has anybody had any experience with coding for administration of lidocaine through a sphenocath for treatment of headaches.  It has been suggested to use 64505 which is an injection of the sphenopalatine ganglion.  However, it appears that Lidocaine is pushed through the cath and absorbed through the mucouse membrane which to me is not an injection.


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## dwaldman (Feb 4, 2016)

Below is the Q & A from the AMA describing the "injection of the sphenopalatine ganglion":

AMA CPT Assistant July 2014 page 8

Frequently Asked Questions:Surgery: Nervous System

Question: My physicians are using a device to deliver medication through the nose when a sphenopalatine ganglion block is performed under fluoroscopic guidance for patients with migraine headaches. What is the appropriate code(s) to report? 

Answer:There is no specific CPT code that accurately describes this service. The code set includes code 64505, which describes the injection of the sphenopalatine ganglion; however, it is inappropriate to report this code. Therefore, the unlisted code 64999, Unlisted procedure, nervous system, should be reported. When reporting an unlisted code to describe a procedure or service, it may be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and the need for the procedure, as well as and the time, effort, and equipment necessary to provide the service.


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## Whitteds (Apr 20, 2016)

*SPG Block via SphenoCath Device Response from device Rep*

What is the correct way to bill for a SPG Block that is done with the SphenoCath device? The SphenoCath device rep provided the following response when I suggested the correct code was the unlisted code (64999) since the SphenoCath uses an intranasal approach to deliver topical lidocaine to the SPG and surrounding nerves.

 SphenoCath Rep Response:
 There apparently are CPT Assistant comments out there about the 64505 CPT code. The previous CPT Assistant inquiries stating that 64505 is not appropriate did not mention the SphenoCath® device and was not an accurate description of the procedure using the SphenoCath® device so we believe it is not dispositive on the issue of the correct code(s) to use. The inquiry describes using an unspecified “device” to “deliver” some “medication” though the nose. Based upon that generic description, the response was that 64505 was not an “appropriate” code without giving any reason why. We believe that the response given was not applicable to procedures using the SphenoCath® device for several reasons.

 First, the inquiry did not specify the device. Second, the SphenoCath® device is used to inject anesthetic as the CPT code describes (not “deliver” it, which is not what the CPT code describes). Third, the inquiry described delivery of “medication” while the SphenoCath® injects anesthetic. Fourth, the inquiry does not specify that an SPG block (or Trigeminal nerve block) is being performed as is the case with a procedure using the SphenoCath® device.

 Based upon the above, the inquiry and response do not appear to be addressing the SphenoCath® device at all but may in fact be addressing the Tx360 device from Tian Medical, which is completely different (both in physical properties and how it is used procedurally) from the SphenoCath® device.

 Billing personnel occasionally claim that the SphenoCath® device does not qualify as an injection for purposes of CPT code 64400 or CPT code 64505. No insurance company has ever brought up that question in over 3 years of claims being submitted. The term injection is not defined for either 64400 or 64505 while it is defined for purposes of other CPT codes. Therefore, it is not possible to categorically state that a SphenoCath® device administration does not qualify as an injection for purposes of 64400 or 64505. The term injection means “any pressurized delivery of injectate by pump, drip, or pressurized piston syringe... through needle, catheter, or cannula into an IM, IV, SQ, potential space, or other body cavity." The SphenoCath® device certainly qualifies under that definition. It is also well known that there are a number of medical procedures that do not involve a percutaneous delivery that are nonetheless called injections (for example sub-Tenons injections using a cannula).

 In addition, a consultant’s inquiry to the AMA’s Knowledgebase requesting a definition of injection for purposes of 64505 resulted in the AMA responding on February 11, 2015 as follows:

 Response from: CPT KnowledgeBase - 02/11/2015 10:30 AM

 This is written in response to your Electronic Inquiry (EI) #9167 referencing EI's 9104 and 9139. From a CPT coding perspective and based upon the facts provided in your electronic inquiry please be advised that your inquiry was forwarded to our CPT Specialty Advisor representing the American Academy of Pain Medicine. Based upon comments received from our physician advisor and in response to your question, "this description does meet the requirements for 64505."

 It appears that the AMA is clearly acknowledging that the SphenoCath® device administered SPG block does qualify as an injection for purposes of 64505 (and by extension to CPT code 64400). In any event, the CPT code is clear that SPG blocks and Trigeminal nerve blocks have separate and clearly identified procedure codes which are to be used when these procedures are performed.


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## BeckyGK (Oct 12, 2016)

*SPG block using Sphenocath Device*

I am reluctant to use the answer from the Sphenocath device representative as the information does not say what facts were sent to the AMA to review.  

The AMA CPT Assistant July 2014 page 8 article is pretty clear on a device being used being coded as 64999.
I would like to see more information with the Sphenocath device being named from CPT Assistant before I would be comfortable using 64505.

I understand the Sphenocath is different than the other devices, but it is still topically administered to the mucosa.

The use of the Sphenocath is still not the original intent of the CPT code 64505 in that an injection is done into the Sphenopalatine Ganglion.
It seems to me the Sphenocath procedures scope of work would be different and the RVU's would not be the same.

What do you think dwaldman?


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## dwaldman (Oct 17, 2016)

BeckyGK , the SphenoCath representative response within in this thread brings to light the question regarding transnasal injections of medications targeting the sphenopalatine ganglion. I agree solely using cotton tip applicators or an unspecified "device" would fall under 64999. But I think a follow up question with the AMA with more specificity to the type of catheter and technique used could potentially warrant further insight into transnasal approach reporting.


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