# 4th Genicular Nerve for 64454



## karnathm (Mar 4, 2020)

We have providers that inject a fourth nerve when doing genicular nerve blocks.  Do you think this should be included in 64454 or separated out as a peripheral nerve 64450? Does anyone know if 64454 is limited to injection of only the superolateral, superomedial, and inferomedial genicular nerves?

*Terminal branch of the nerve vastus intermedius
Op Note*
PROCEDURE:
Diagnostic block of the superior medial, superior lateral, inferior medial genicular nerves and terminal branch of the vastus medialis of the right knee, under Fluoroscopic Guidance.
Four 22-gauge 3-1/2 inch Quincke needles were utilized. Each was placed and advanced under fluoroscopic guidance to the junction of the medial and lateral femoral condyle and shaft, the medial tibial condyle and shaft, advanced until 50% across the shaft in lateral view. A  fourth needle was placed in the superior patellar space at the midpoint of the femoral shaft. Needle positions were confirmed in true AP and lateral views. After negative aspiration each was injected with 1 mL of 0.5% ropivacaine. The needles were then withdrawn.

*Anterior descending articular branch block
Op Note*
PROCEDURE PERFORMED:
Diagnostic bilateral-sided genicular nerve blocks including 
Superolateral genicular nerve block
Superomedial genicular nerve block
Inferomedial genicular nerve block
Anterior descending articular branch block
Under fluoroscopic guidance.
After anesthetizing the skin and subcutaneous tissue with 1% buffered Lidocaine, a 22-gauge spinal needle was placed at the junction of the shaft of the femur with the medial and lateral epicondyles and the shaft of the tibia with the medial epicondyle. For the anterior articular branch, another needle was placed in the midline about 4 cm above the superior margin of the patella until the femur was contacted. In lateral views, the needles were adjusted and they were placed at 50% of the diaphysis of the femur and the tibia. Aspiration was negative. A small amount of Isovue was injected to rule out vascular uptake. This was followed by solution of Bupivacaine 0.25%, volume 1 mL at each level. No complications were noted. 

Thank you,


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## dwaldman (Mar 11, 2020)

Below is from AMA CPT Changes 2020

"1 unit for any number of genicular nerve branches, with a required minimum of three nerve branches"

"Code 64454 has been established to report injecting the superolateral, superomedial, and inferomedial genicular nerve branches. If all three of the listed nerve branches are not injected, then code 64454 should be reported with modifier 52 appended to indicate a reduction in service. An exclusionary parenthetical note has been added to preclude reporting code 64454 with new code 64624 (destruction by neurolytic agent of genicular nerve branches)."

Clinical Example (64454) A 78-year-old female has a five-year history of persistent right knee pain that is interfering with her ability to complete ADLs. She has had poor control of her pain despite multiple medication trials and PT. Due to her persistent, debilitating pain, a trial of genicular nerve blocks is scheduled to relieve her pain and improve her function.

Description of Procedure (64454) Identify the appropriate skin and bony landmarks. Perform the procedure under fluoroscopic guidance. Target the superolateral, superomedial, and inferomedial genicular nerves adjacent to the periosteum on the medial aspect of the tibia, and at both the medial and lateral aspects of the femur at the junctions of the shaft and the epicondyle. Under imaging guidance, approach the target areas by introducing a spinal needle from either an anteroposterior or lateral entry point with the final position residing adjacent to the bone. After negative aspiration, deposit local anesthetic at each of the sites. Remove the needle and stylet.


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