# Billing 01402with 64448



## jijikaren (Aug 17, 2011)

We billed 01402 with 64448-59 modifier, 01402 was paid but 64448 denied requesting medical notes. 
Is this how to code for post operative pain injection (sciatic block) by the same anesthesiologist on same day
Could anyone help if you have such at your practice.
thanks


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## cindyt (Aug 17, 2011)

A sciatic pain block placed for post operative pain should be coded 64445.  You must also append the modifier -59.


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## dwaldman (Aug 17, 2011)

Possibly linking 338.18 acute postop pain to block or infusion if this represents the indication for the procedure.

Below I saw on CPT Assistant which is an interesting overview of 64445-64448

Sciatic Nerve

Let us now turn our attention to the codes for an injection of an anesthetic agent to the sciatic nerve.

64445Injection, anesthetic agent; sciatic nerve, single

64446Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter, (including catheter placement) including daily management for anesthetic agent administration

Before code 64445 was revised in 2003, it did not identify the number of injections (blocks) of the sciatic nerve. As a result of the revision, code 64445 now refers to a single injection (block) of the sciatic nerve. Code 64445 does cover the sciatic nerve blocks that are used for immediate post-operative pain control and occasionally for ischemic conditions, reflex sympathetic dystrophy (chronic regional pain syndrome), or other painful conditions of the lower extremity.

As in the case of the brachial plexus single injection nerve block (code 64415), the 2003 code descriptor modification of 64445 was essential to reflect appropriate reporting of the new procedure, continuous sciatic nerve block. As a result, code 64446 was added in 2003 as a mechanism to report continuous sciatic nerve block. This code is reported for the continuous administration of local anesthetic via a catheter for postoperative pain control and/or chemical sympathectomy. This continuous procedure is used for several days for treatment of regional ischemia of the extremity, for postoperative pain control with reconstructive procedures on the foot and ankle, as well as the posterior knee. Additionally, it may also occasionally be used for the treatment of reflex sympathetic dystrophy and chronic pain.

To obtain a better understanding of the sciatic nerve blocks, let us look at the intra-service work associated with codes 64445 and 64446.

Code 64445

Informed consent is obtained preoperatively. In the postanesthesia recovery room or in the operating room after surgery on the foot and ankle is completed, the patient is placed in the right lateral position and the thigh flexed on the hip to 45?. The posterior superior iliac spine (PSIS), the greater femoral trochanter, and sacral hiatus are identified and marked. A line is drawn between the superior and posterior aspect of the greater trochanter and the PSIS. The line is bisected and a perpendicular dropped 3-5 cm from the midpoint of the line to the needle insertion site. The point of insertion should lie along a third line drawn between the greater trochanter and the sacral hiatus. The skin is prepped and draped and a 6-in, 22-gauge, short-bevel insulated nerve stimulator needle is advanced perpendicular to the skin. The needle is advanced 6-8 cm with a stimulation intensity of 1.5-2.0 mA and adjusted downwards as evoked motor response increases. Plantar flexion at less than 0.5 mA is the desired goal and indicates placement of the needle near the medial part of the nerve. After a negative aspiration, the needle is held firm and local anesthetic injected incrementally. Attention is paid to the presence of paresthesias, reflex movement, and resistance to injection. Efficacy of the block may be improved by depositing the local anesthetic in more than one location, such as laterally (peroneal component) and medially (tibial component). The mean duration of analgesia is 14 hours but can range up to 24 hours.

Code 64446

Informed consent is obtained preoperatively. In the postanesthesia recovery room or in the operating room after surgery on the foot and ankle is completed, the patient is placed in the right lateral position and the thigh flexed on the hip to 45?. The greater femoral trochanter and ischial tuberosity are marked and a line is drawn from the popliteal fossa to midway between the two landmarks. A 20-gauge insulated needle is introduced vertically to the skin, just medial to the upper end of the marked line to determine the depth of the sciatic nerve. A brisk motor response in the ankle, foot, or toes is noted with less than 0.4 mA stimulation.

Next, an insulated Touhy needle is advanced from approximately 5 cm cephalad and angled to intersect the tip of the first needle. Nerve stimulation is again noted and a catheter then advanced through the Touhy needle 50-100 mm. The electrical connection is then transferred to the catheter and nerve stimulation is again noted. The Touhy needle is removed, the catheter sutured in place, a bacterial filter is attached, and 15-20 ml of local anesthetic is injected through the catheter. Block of the sciatic nerve is then accessed over the next 15-30 minutes and an infusion of local anesthetic started. Required infusion rates typically range from 2-12 ml/hr. Occasionally, bolus injections (10-15 ml) are required. The infusion is usually stopped at about 48 hours postop.

The complications of a continuous sciatic nerve block include possible infection, injury to the sciatic nerve with neuralgia, and systemic local anesthetic toxicity. Fortunately, these complications are rare.

Over the next several days, the continued efficacy and function of the block is evaluated and adjustments in the infusion made as necessary. This continued follow-up is included in the new code for continuous sciatic nerve block.

Femoral Nerve

The last two nerve block injection codes we will review are specific to the femoral nerve and were added in CPT 2003:

64447Injection, anesthetic agent; femoral nerve, single

64448Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration

Code 64447 is reported for a single nerve block injection, while code 64448 is reported for continuous administration of local anesthetic via a catheter for postoperative pain control and/or chemical sympathectomy. Such continuous procedures are used to provide pain relief, a reversible sympathectomy or increased blood supply to the lower extremity for several days. Additionally, this continuous procedure may be used for ischemia of the lower extremity, postsurgical pain relief, and occasionally for reflex sympathetic dystrophy and chronic pain. However, the primary use of this procedure is for postoperative pain control after surgery on the leg and knee, particularly after total knee arthroplasty.

To obtain a better understanding of the femoral nerve blocks, we will take a closer look at the intra-service work associated with codes 64447 and 64448.

Code 64447

Informed consent is obtained preoperatively. In the postanesthesia recovery room or in the operating room prior to general anesthesia, the patient's right groin is prepped with a betadine solution and a 22-gauge, short-bevel 4-cm needle is inserted approximately 1 cm lateral to the femoral artery and 1 cm caudad from the inguinal ligament after anesthetizing the skin with a small amount of local anesthetic. The proper location of the needle is ascertained with the use of a nerve stimulator, the elicitation of paresthesias, the loss of resistance technique, or with a field block technique. Next, between 15 and 30 ml of local anesthetic is injected carefully and with frequent aspiration to avoid the possibility of intravascular injection. The density and function of the block is then assessed. Onset of block may take 30-40 minutes. Postoperative analgesia typically lasts 12-24 hours.

The complications of a femoral nerve block include possible infection, injury to the femoral artery with hematoma formation, systemic local anesthetic toxicity, and nerve injury. Persistent quadriceps weakness may suggest neural injury. Fortunately, these complications are rare.

Code 64448

Informed consent is obtained preoperatively. In the postanesthesia recovery room or in the operating room prior to general anesthesia, the patient's right groin is prepped with a betadine solution and a 22-gauge, short-bevel 10-cm insulated needle is inserted into an 18-gauge long plastic cannula. The femoral nerve is located approximately 1 cm lateral to the femoral artery and 1 cm caudad from the inguinal ligament after anesthetizing the skin with a small amount of local anesthetic. The proper location of the needle is ascertained with the use of a nerve stimulator or with the elicitation of paresthesias, or both. The plastic cannula is then advanced over the needle into the “sheath” of the femoral nerve. Next, between 20 and 30 ml of local anesthetic is injected carefully through the cannula and with frequent aspiration to avoid the possibility of intravascular injection. A 20-gauge epidural catheter is threaded through the cannula and the cannula is removed. The catheter is sutured in place and sterilely dressed. Local anesthetic is then infused.

The complications of a femoral nerve block include possible infection; injury to the femoral artery with hematoma formation; systemic local anesthetic toxicity; and nerve injury from direct trauma, intraneural injection, or compressiveischemic injury. Persistent quadriceps weakness may suggest neural injury. Fortunately, these complications are rare.

Over the next several days, the continued efficacy and function of the block is evaluated and adjustments in the infusion made as necessary. This continued follow-up is not included in the new code for continuous femoral nerve block.

It is important to note the cross-reference following codes 64416, 64446, and 64448


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## jijikaren (Aug 18, 2011)

thanks, one more question, the provider did not document the time for the injection on the report, only the anesthesia time, could this be a problem?


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## dwaldman (Aug 18, 2011)

Since this was the means for anesthesia and you are reporting the anesthesia code to report this, the start time could be when the physician..... as described by the claims processing manual.....

"Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished on or after January 1, 2000, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption."


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