# Coccygeal Plexus Block



## lorilynn222 (Jul 7, 2011)

We are trying to figure out the most accurate code to report for a coccygeal plexus block and are coming up with a variety of different ways this is being coded. I've seen 64520 and 64450 both used. Any ideas? thanks


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## valbat (Jul 8, 2011)

we code 64999 which is unlisted for coccxgeal injection.


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## dwaldman (Jul 9, 2011)

http://libweb.allencc.edu/Netters/NettersPlate184.html

In the above link it show the sympathetic trunk traveling down to the coccyx but in the link below near the coccyx area they are describing the ganglion impar which an unlisted code 64999. Also I questioned 64520 due to the fact  the descriptor for 64520 states thoracic or lumbar only and does not mentioned below that.


http://en.wikipedia.org/wiki/Ganglion_impar


"The pelvic portion of each sympathetic trunk is situated in front of the sacrum, medial to the anterior sacral foramina. It consists of four or five small sacral ganglia, connected together by interganglionic cords, and continuous above with the abdominal portion. Below, the two pelvic sympathetic trunks converge, and end on the front of the coccyx in a small ganglion, the ganglion impar (or ganglion of Walther)."

From Pain Management Answer Book they describe the sympathetic nerves in thoracic-lumbar area in terms of how they contribute to feelings of pain

Pain Management Answer Book Effective Date 01/10/2005 Publish Date February 2005 Subject Sympathetic Nerve Blocks and Nerve Destruction SYMPATHETIC NERVE BLOCKS AND NERVE DESTRUCTION The nerves of the body constitute a critical communications system. Afferent nerves transmit important sensory information from the skin and organs to the central nervous system while efferent signals are instructions sent by the central nervous system back to muscles and internal organs. Sympathetic nerves, located in the thoracic-lumbar area, are a subset of afferent nerves. They allow the body to monitor and control autonomic body functions (e.g., heart rate, respiration, digestive functions, etc.) in cases of emergency. Sympathetic nerves are not normally a cause of pain. When sympathetic nerves are damaged or diseased, painful symptoms can result. Because damaged sympathetic nerves often result in a number of inter*related symptoms, pain specialists refer to the resulting condition as Complex Regional Pain Syndrome (CRPS). There is Complex Regional Pain Syndrome type I, which replaces the formerly used term, Reflex Sympathetic Dystrophy (RSD), and Complex Regional Pain Syndrome type II, which replaces the formerly used term causalgia. CRPS is most commonly associated with limb disorders. The most typical example involves the arm. A patient with CRPS may experience a burning sensation in the hand or arm, a hypersensitivity to touch, stiffness, discoloration of the skin and general weakness. Of these symptoms, the most obvious evidence of sympathetic nerve damage is intense, burning sensation in the limb where there is specific nerve damage, known as CRPS II. 


Below I found a definition of the coccygeal plexus but via the internet there was not a lot information of this:
a small plexus formed by the fifth sacral and coccygeal nerves

I agree I have seen 64450 mentioned for coccygeal nerve block without really an in depth look at what the exact approach is and final needle placement, which makes this code sometimes questionable. You are mentioning the coccygeal plexus block which I had not seen before and agree with your previous response that 64999 might the most appropriate code.


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## preserene (Jul 9, 2011)

This coccygeal plexus is formed by the fifth sacral nerve (with a contribution from S4) and the coccygeal nerve. 
That is, the ventral branches of the 4th to 5th sacral spinal nerves and the coccygeal spinal nerve (S4-Co1) interlink to form the coccygeal plexus. It pierces the anococcygeal ligament to supply sensory innervation to the skin of that region.) 

*So the plexus is from S4, S5 and Caccygeal spinal nerves.*Why don't we give qualification for 64483/ 64483 + 64484, instead of going for unlisted code ( that is always there!).

The ganglion impar (sympathetic) does not have a picture here.
A plexus is different from ganglion. Ganglion impar is fromed by five ganglion of sacral.

The next question is where to consider the *spinal nerves *(forming the plexus) - to the codes of the paravertebral facet joint or facet joint nerve (6448x series 
*OR*the *peripheral nerves *series - 64450 ?

It is appropriate to code it is in the paravertebral/facet series- 64483 if single facet joint level
*64483, + 64484*,  if more levels.

I would definitely check for 64483/ + 64484, instead of going for unlisted code if the doctor went through the paravertebral
Do I make some sense ??!!


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## dwaldman (Jul 11, 2011)

"So the plexus is from S4, S5 and Caccygeal spinal nerves.Why don't we give qualification for 64483/ 64483 + 64484, instead of going for unlisted code ( that is always there!)."

In response, I think they would have provide the procedure note to see the approach but currently I am not aware of descriptor describing coccygeal plexus block. Looking lumbar plexus block which is considered unlisted. I would be hestitate to be able to say you can use the tranforminal epidural codes for this.

The ganglion impar (sympathetic) does not have a picture here.
A plexus is different from ganglion. Ganglion impar is fromed by five ganglion of sacral.

In response, the reason this mention because the question was asking about 64520 and the description that I saw show the sympathetic trunk ending at ganglion impar.

The next question is where to consider the spinal nerves (forming the plexus) - to the codes of the paravertebral facet joint or facet joint nerve (6448x series 
ORthe peripheral nerves series - 64450 ?"

In response, as mentioned in CPT Assistant the last facet level is L5-S1 I would not consider a facet joint nerve block for this.

I would definitely check for 64483/ + 64484, instead of going for unlisted code if the doctor went through the paravertebral

In response, they are not saying the physician blocked S4 and S5 at Sacral foramen what is the code for this. Although I am not aware of the technique to perform a coccygeal plexus block with no descriptor describing this personally I would lean towards unlisted code but I understand your points.


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## preserene (Jul 12, 2011)

Dwaldman, Thank you very much.You discussed it so well and I am pleased with the explanation with the very little info availed to us. 
I  cannot picture the procedure  and technique  as well, the approach, neither. 
However I am curious. So the final output is the unlisted code , if not for the peripheral nerve injection. I would like to know  when the ball comes out from the payer's court!! 
Thank you again.


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## dwaldman (Jul 12, 2011)

The ironic thing is last night I was searching the internet for a ICD-9 for a brain MRI impression that I needed to bill and it read small vessel ischemic disease and saw a post that you were involved in that was very helpful in regards to 443.9 versus 437.1 from a cache from the diagnosis coding forum on this site. In the particular thread like this situation there is not anything that exactly spells how to code it and the posts went back in forth in discussing it but although there look like disagreement in some of the posts it was informative discussion for me to help me get to the next ticket.

Last year one of the doctors I was working with was doing coccygeal nerve block with a very vague procedure note. I sent a request to the AMA CPT Network if they would accept CPT 64450 as a code to report for a coccygeal nerve block versus using unlisted Here is part of my response. (They did not mention they sent it to the speciality societies for guidance.)

"Based solely upon the information provided in your electronic inquiry, from a CPT coding perspective, code 64450, Injection, anesthetic agent; other peripheral nerve or branch, should be reported to describe a “coccygeal nerve block”."

Although I received this response that for a coccygeal nerve block that I could use 64450, there still questions in my mind that techniques can vary on this particular procedure making it unlisted in some cases and with the coccygeal plexus block, I think if would call it this they would said there is no code that represents the mentioned procedure.


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