# third occipital nerve block



## dwaldman (Apr 14, 2010)

Following informed consent, the patient was positioned prone on the fluoroscopy table. A time out was performed. The patient was monitored and sedated per anesthesia. A sterile prep and drape was done. After initial fluoroscopic localization, 1% lidocaine was used for local anesthesia, followed by insertion of 22 gauge needles; they were advanced to the waistpoint of the transverse processes of C2, C3, & C4. After injection of the C3 process, the needle was repositioned to the C2-3 disc area (corresponding to the course of the TON). Following negative aspirate and fluoroscopic confirmation of needle position, the patient received 1 cc of a solution of 3 cc 0.25% Marcaine + 80 mg Depo-Medrol at each of the locations. The patient was observed in the recovery room for an appropriate amount of time following the procedure.

The performing provider suggested 64490 LT 64491 LT 64492 LT but I said to him the corresponding facets would be C2-C3, C3-C4. He said he was thinking 64492 also since he also blocked the TON. Please assit on how you bill for the TON is it with the Facet codes and with it is at the same level as other blocks.


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## rkmcoder (Apr 14, 2010)

(These are my opinions and should not be construed as being the final authority.  Other opinions may vary.)

The TON (third occipital nerve) is also known as the lesser occipital nerve, and would be coded either 64450 or 64413, depending on your preference.  Doing an internet search, I would probably code it 64450 because most TON block info references this code.  There is conflicting info on one web site that actually lumps the TON block into the facet block (http://www.algosresearch.org/Education/ISISGuidelines/AbridgedGuidelines.html), but since there were three injections that corresponded to two facets, then I would code your example above simply as 64490, 64491.  If the TON was injected as a byproduct of the facet injections, then so much the better, but to code it you would have to use another needle just for that.

Richard Mann, your pain management coder
rkmcoder@yahoo.com


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## dwaldman (Apr 14, 2010)

Thank you for the response. I read thru the link and looked at the information and picture of the TON>If I ask the doctor if he blocked because he believes it innervates the joint would I being doing extra billing by also billing another code other just one facet code for that level.


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## rkmcoder (Apr 15, 2010)

(These are my opinions and should not be construed as being the final authority.  Other opinions may vary.)

The operative report indicates that the needle was 'repositioned' to perform the TON block.  Two procedures cannot be coded if done thru the same needle.  I know that your physician wants paid for everything he/she did, but he/she shortcutted the system by using the same needle for multiple procedures.  Keep in mind that reimbursement for top level procedures (as opposed to add-on procedures) include fees for supplies, salaries, malpractice, etc.  In this case, if both procedures were coded, then you physician would be paid twice for these items.  An audit would prompt a refund or sanctions.

Richard Mann, your pain management coder
rkmcoder@yahoo.com


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## dwaldman (Apr 15, 2010)

Thank for this insight.  Regardless whether the physician feels it should be bill as three levels I am the one that is going to put in the charge and responsible for it coded as the appopriate levels.


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