# Nerve Blocks - I'm new to pain managment



## AR2728

I'm new to pain managment and my physician supplies the CPT codes--but I don't think they are correct.  Will someone please assist me with the following procedures and what CPT codes should be billed?  

_25 GHypodermic needle used
20 mg depo medrol for each auriculotemporal nerve
.25% Bupivacaine-4 cc for each auriculotemporal nerve block, 2cc for each supraorbital nerve block

*Supraorbital nerve block*:  All pressure points padded and the forehead was prepped and draped...hypodermic needle was advanced until reaching the peristeum, followed by injection in a fan like distribution to cover RIGHT supraorbital and supratrochlear nerve.  Repeated aspirations throughtout the injection were negative for air, CSF and blood with incremental attempts.  Mediation as mentioned above then injected covering the nerves.  The same procedure was repeated on the LEFT side. 

*Auriculotemporal Nerve Block*: ...prepped and draped... Temporal artery was marked and the hypodermic needle was advanced posterior to the temporal artery until reaching the peristeum.  Needle withdrawn until the patient got paresthesia.  Med injected as mentioned above in a fan like distribution to cover the RIGHT auriculotemporal nerve.  Repeated aspirations negative....  Same procedure done on the LEFT side.  _

Physician stated to bill 64400 and 62280-50-------I think this is incorrect especially the 62280.  I was looking at codes 64400-64405.  I am so lost and would really appreciate any advice.  One more question---Would I bill separately for the Bupivicaine?


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## dwaldman

Below is from AMA CPT Assistant 2008 and addresses injecting separate branches or divisions of the trigeminal nerve. If you have AMA CPT Assistant online you have to search under supraorbital to find this article. It does not pull under 64400 for some reason. The procedure note you provide does describe targeting both the supraorbital and supratrochlear but the fan like distribution in a single injection would be reported as one unit of 64400. 

".....injection in a fan like distribution to cover RIGHT supraorbital and supratrochlear nerve."

Per Anesthesia Coding Alert thru Supercoder/The Coding Institute, they suggest to report 64450 for the Auriculotemporal nerve block.  I ran a CCI check on their site, and it shows there is no code pair/bundling issue with 64400 and 64450 

I looked at the AMA CPT Network for description of CPT 66280 and it describes a neurolytic substance being injected. This is not supported in the documentation you provided. So I would review the reason 62280 would not be appropriate code selection. So future collaboration with the physician can be a combination of physician clinical knowledge and experience and coding support by providing resources to support code selection

CPT Code: 62280 

Clinical Example

A 45-year-old man with extensive rectal carcinoma involving the left lumbosacral plexus has intractable left perirectal pain but has lost much of his control of both bladder and bowel function. Various systemic medications (oral narcotic and nonnarcotic), physical therapy, radiation therapy, and chemotherapy have all failed to provide significant long-term pain relief. There is no further operative resection possible for the tumor. This patient is a good candidate for a neurolytic injection because of the severity of the pain and the diminished control of bladder and bowel function. A neurolytic injection to ablate the left S2-4 nerve roots is recommended.

Description of Procedure

no Description


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AMA CPT Assistant December 2008 page 9

Surgery: Nervous System, 64400 (Q&A) 

Question: If a provider injected two separate unilateral branches or divisions of the trigeminal nerve (eg, injected the right supraorbital branch [V1] and also injected the right infraorbital branch [V2]), would these injections be reported as two units of code 64400 or just one unit, as the code description states "any division or branch"? 

Marvel J. Hammer, RN., Denver, CO

Answer: Code 64400 should be reported once for the injection into the right supraorbital nerve. Code 64400 with modifier 59, Distinct procedural service, appended should be reported for the right infraorbital branch injection. The descriptor of code 64400 represents a single injection into a single nerve in the anatomy and sensory distribution of the peripheral trigeminal nerve. Injection of each specific nerves has effects on different anatomy sensation in different areas. 

An understanding of the neural distribution is key, since the right supraorbital nerve is above the orbit of the eye (about at the level of the eyebrow on the forehead), whereas the infraorbital nerve is below the orbit (lateral to the nose, middle of the face, and midline with the pupil of the eye). 

To illustrate, the trigeminal nerve is the main cutaneous sensory nerve of the face and head, with three main branches (V1, ophthalmic; V2, maxillary; and V3, mandibular), each with its own nerve divisions. The right frontal nerve is a continuation of the ophthalmic nerve. The right supraorbital nerve leaves the orbit through the supraorbital foramen, providing filaments to the upper eyelid and the frontal muscles. The right infraorbital nerve is in the maxillary branch of the trigeminal nerve. The maxillary nerve becomes the infraorbital nerve, which emerges onto the face through the intraorbital foramen, thus providing cutaneous innervation to the middle of the face, lower eyelid, side of the nose, and upper lip.


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## AR2728

Thank you so much for all the information.  This is extremely helpful.  I appreciate it!


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