# L5-S3 Denial of 64450 - HELP



## celcano (Oct 2, 2018)

Hi, all!  I am really confused now and need some expert assistance.  I have been in Pain Management billing for 4 years.  I was always taught that when we did an L5-S3 nerve block that we billed 4 units of 64450.  My physician, who attends coding classes with us, feels the correct way to code this is 64450 X 4.  We have been fighting with our state Medicaid as they only want to pay for 3 units.  I have just received an "Edit Clarification" for 64450 from them.  I have attached their response (scroll to attachment below). 

To add the confusion, I found this from AH"IMA from 05/29/2015:
 "QUESTION 3
A patient was seen at our facility and underwent a left-sided L5 and S1, S2, S3, and S4 lateral branch nerve block for diagnostic purpose with C-arm fluoroscopy. What are the correct codes for a lateral nerve block?

ANSWER
Based on the operative report a medial branch nerve block was performed at the L5 and a lateral branch nerve block was performed at the S1, S2, S3 and S4.

Therefore, it would be appropriate to report CPT code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapohphyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level, for the L5 medial branch block.

For the 4 lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch."

It has been my understanding that we can't bill a 64493 because we are not blocking a joint.  Are we incorrectly coding a L5-S3 nerve block with 64450 X 4?  If not, then how do I fight this.  I can't find anything that definitively states this other than ablations of L5-S3 nerves are coded with 64640 X 4.  We submitting that to them and, again, they came back with the attachment below.

Any assistance will be GREATLY appreciated.

ADDED ATTACHMENT INFORMATION - MEDICAID EDIT CLARIFICATION
"Procedure 64450 is used to report the introduction/injection of an anesthetic agent into a peripheral nerve or branch.  A peripheral nerve refers to any motor and/or sensory nerves and ganglia that exists outside the brain or spinal cord that is not specifically listed elsewhere in CPT.

The Global Duplicate Value is the total number of times per date of service that a given procedure may be appropriately submitted.  This is reflective of the total number of times it is clinically possible or clinically reasonable to perform a given procedure on a single date of service across all anatomic sites.  After the maximum number of times is reached, additional submissions of the procedure are not recommended for reimbursement.  Duplicate values are assessed for accuracy based on the number of submissions of a specific procedure according to anatomic sites and CPT/CMS guidelines.

Procedure 64450 is typically used for dorsal branch paravertebral nerve injections undertaken at several levels.  An example is facet nerve injections which can done multiple levels and would encompass 3 branches, unilaterally or bilaterally (6 total)."


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## mcpalmeter (Oct 2, 2018)

*L5-S3 Denial 0f 64450*

Email me the attachment.  I cannot open it here.
maryannpalmeter@yahoo.com


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## josephmglick (Oct 10, 2018)

We have always done 6449_ series for blocks for anything other than S1, S2, S3, S4 (64450 is the correct code, The lateral branches of the dorsal sacral nerve plexus are considered peripheral nerves). The description of the 6449_ codes states paravertebral facet (zygapophyseal) joint (or nerves innervating that joint). If you read bullet point 4 below it states if the injection is made around or into the spinal nerve, the service should be billed as a paravetebral nerve injection. I got this information from a previous LCD from the local MAC and was used to educate my physicians.

Paravertebral Facet Joint Injection
1. Each CPT code listed (single level, second level, third and any additional levels) may be billed with a
Modifier 50 when injecting a level bilaterally. For one level unilateral or bilateral CPT codes 64490 or
64493 should be used. If the facet joint injection is performed at more than one level unilateral or bilateral
CPT codes 64491, 64492, 64494 or 64495 should be used for the additional levels. For bilateral
procedures Modifier 50 should be appended to the procedure codes with number of services of one.
2. Use the appropriate CPT code in Item 24D on the CMS-1500 claim form (or electronic equivalent) and
link it to the applicable ICD-9-CM code listed above under the ICD-9-CM Codes that Support Medical
Necessity section.
3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64490-
64495.
*4. If the injection is made around or into the spinal nerve, the service should be billed as a paravertebral
nerve injection.*
5 When destruction of the facet joint nerve is performed following the blockage, only the codes for the
nerve destruction should be billed since their allowance includes that of the facet nerve blockage
procedure.


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## aparnita bakshi (Oct 12, 2018)

*Facet joint nerve block*

According to the AMA, the code series for medial branch blocks and the facet joint injections are the same (i.e., CPT series 64490-64495), with reporting based on the number of facet joints injected, not the number of nerves injected. For example: If three (3) medial branch nerves are injected only two (2) facet joint injection codes would be reported despite the fact that three nerves were injected, since each facet joint is connected to two medial nerves.
Therefore, it would be appropriate to report CPT code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level, for the L5 medial branch block.

S1, S2 and S3 will be considered as lateral branch blocks and lateral branch nerve is a peripheral nerve that would be reported with CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, when a lateral branch nerve block is performed. 
Please note: CPT code 64450 should only be reported per nerve or branch and not per injection. Report multiple units of the injection for the three lateral branch block injections performed.

FYI, as per CPT Assistant:
Procedurally, the work of the described SI joint destruction differs from that described by code 64622, Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level. Code 64622 may be reported for L5-S1 rhizotomy (nerve destruction since this joint lies between two spinal segments for which the anatomy and procedural work at L5-S1 is similar to that at other spinal segments (e.g., L4-5). Therefore, the unlisted nervous system code 64999 would be reported once for SI joint or sacral rhizotomy (nerve destruction). 

To differentiate between the work when performing sacral nerve destruction of S1, S2 and S3 each individually separate peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, code 64640 is reported four times. It is suggested that Modifier 59, Distinct Procedural Service, be appended as well.


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