# Piriformis Nerve Block



## WENDYBHOLLOWAY (Feb 9, 2016)

Curious to know what CPT code is used to bill for a Piriformis Nerve Block?  We are billing 64445 and this is not covered in the ASC for Tricare.  My doctor has asked if there is another code that would be sufficient or if 64445 the correct code.

Thank You,
Wendy Holloway, CPC
Albany, Ga


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## abrodskycpc (Feb 9, 2016)

That is the same code that I use!


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## masseytc (Feb 9, 2016)

I found on the website FIND-A-CODE the following:  The CPT Assistant clarifies that sciatic nerve injection (64445) should not be used to report a piriformis injection as the work involved in a sciatic nerve injection is substantially more than that which is required in a piriformis injection. The pain is caused from the pinch or pressure on the sciatic nerve but the root of the cause is muscle spasms in the piriformis muscle that keeps it tight and placed this pressure on the sciatic nerve that then becomes painful.  Instead, 20552 would be the best code to report.  Also report fluoroscopic guidance and ultrasound guidance when performed.  Hope this helps.


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## dwaldman (Feb 10, 2016)

Below is from AMA CPT Assistant, if the provider is performing a piriformis muscle injection the correct code selection per the AMA is CPT 20552. CPT 64445 would only be applicable if the sciatic nerve is specifically being blocked


AMA CPT Assistant
April 2012 page 19

Coding Clarificationiriformis Muscle Injection Reporting

In the December 2011 issue of the CPT Assistant (page 8), instruction in the article stated that sciatic nerve injection code 64445, Injection, anesthetic agent; sciatic nerve, single, should not be used to report a piriformis muscle injection. However, from a CPT coding perspective, piriformis muscle injection(s) should be reported using CPT code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). For further clarification, should fluoroscopic guidance be performed, this is additionally reported using code 77002, Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device. 

AMA CPT Assistant

December 2011 page 8

Piriformis Muscle vs Sciatic Nerve 

This article was updated in April 2012. 

There is a significant difference in the work and procedure, as well as intent, between an injection of the piriformis muscle and the perineural injection of the sciatic nerve. The sciatic nerve injection code (64445) should not be used to report a piriformis injection. However, from a CPT coding perspective, piriformis muscle injection(s) should be reported using CPT code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). For further clarification, should fluoroscopic guidance be performed, this is additionally reported using code 77002, Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device. 

A piriformis injection may be performed when piriformis syndrome is suspected. In this condition, the muscle is believed to impinge upon the sciatic nerve, which may pass close to or actually run through the muscle. Prolonged or repetitive use of the piriformis muscle, causing either hypertrophy or stretching, can potentially induce the impingement upon the nerve, which may cause pain in the buttock. Diagnostic testing to evaluate the piriformis syndrome usually includes pain on palpation; however, the presence of electromyographic abnormalities is variable. In some cases, magnetic resonance imaging (MRI) scanning may reveal the nerve running through the body of the muscle or abnormal increased signals in the proximal sciatic nerve. In the case of piriformis myofascial pain syndrome, it is suspected that muscle strain or injury may result in areas of sustained muscle spasm that produces trigger points and pain in the buttock. 

Injection of the piriformis muscle with local anesthetic and/or steroid in this situation may relieve the pain but may also be diagnostic in nature. In many cases, injections in combination with physical therapy will produce longterm relief. In a small number of patients, further therapy (eg, surgical division of the muscle, injection with botulinum toxin) may be required to obtain definitive relief. Although fluoroscopy may be used to guide some injections, the muscle is best imaged on computed tomography (CT) scan. Currently, there is growing interest in the use of ultrasound to guide these injections, although its use may be challenging in adults. Use of a nerve stimulator to avoid injection into the nerve is recommended when injections are being performed at the midpoint of the muscle. A successful piriformis injection should not have any evidence of sciatic nerve block present. 

The sciatic nerve injection, on the other hand, is a well-documented method intended to provide regional anesthesia or to alleviate acute or chronic pain of the leg and foot. It does not aid in the management of buttock pain. The injection of the nerve should be managed with anatomic landmarks, using guidance via fluoroscopy, ultrasound localization, and/or a nerve stimulator, as necessary, in order to place the medication as close to the sciatic nerve as possible but not within it. In some cases, patients may need light sedation to manage the placement of local anesthetic in the large muscles overlying the target structure, but the patient should be awake to report any manifestation of paresthesia that could indicate intraneural injection. 

The successful injection around the sciatic nerve may alleviate leg or foot pain in the postoperative period. In the case of chronic pain, successful injection of the sciatic nerve may rule out the role of a neuraxial disease process or facilitate passive physical therapy. It may also direct the use of diagnostic and therapeutic maneuvers to the lower extremity and away from the spine.


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## WENDYBHOLLOWAY (Feb 10, 2016)

Thank you all so much for responding.  Your expertise on this subject is greatly appreciated!

Wendy B. Holloway, CPC
Albany, Ga.


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