# Popliteal and Saphenous Nerve blocks



## Davieda Skobel

I have an anesthesiologist doing a popliteal and a saphenous nerve block for post op pain using an ultrasound for needle placement. Does anyone know if I can bill all three procedures and how? i believe both blocks are billed with 64450,done in different positions, one prone, one supine.

Anyone billed this before? Anyone get paid for these?

Thanks in advance for your help.
Davieda/ Columbus


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## dwaldman

I agree you could bill all three codes: 64450, 64450, 76942




http://en.wikipedia.org/wiki/File:Gray826and831.svg

Above shows the separate distribution 

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"The popliteal block is a block of the sciatic nerve at the level of the popliteal fossa. "

"The sciatic nerve is a nerve bundle consisting of two separate nerve trunks, the tibial and common peroneal nerves. A common epineural sheath envelops these two nerves at their outset in pelvis. As the sciatic nerve descends toward the knee, the two components eventually diverge in the popliteal fossa, giving rise to tibial and common peroneal nerves. This division of the sciatic nerve occurs usually between 50 and 120 mm proximal to the popliteal fossa crease. From its divergence from the sciatic nerve, the common peroneal nerve continues its path downward and descends along the head and neck of the fibula. Its major branches in this region are branches to the knee joint and cutaneous branches that form the sural nerve."


"Popliteal blockade results in anesthesia of the entire distal two thirds of the lower extremity, with the exception of the medial aspect of the leg. Cutaneous innervation of the medial leg below the knee is provided by the saphenous nerve, a superficial terminal extension of the femoral nerve. Depending on the level of surgery, the addition of a saphenous nerve block may be required for surgery. Popliteal block alone is typically sufficient as anesthesia for the tourniquet pain, because this pain is the result of the pressure and ischemia of the deep muscle beds."


http://www.nysora.com/peripheral_ne...-Popliteal-Block-Intertendinous-Approach.html

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"The saphenous nerve is the largest cutaneous branch of the femoral nerve. It descends lateral to the femoral artery into the adductor canal, where it crosses anteriorly to become medial to the artery. It proceeds vertically along the medial side of the knee behind the sartorius, pierces the fascia lata between the tendons of the sartorius and gracillis, and then becomes subcutaneous."

"The main landmark for this block is the tibial tuberosity, an easily recognizable and felt bony prominence on the anterior aspect of the tibia a few cm distal to the patella."

"There are several techniques of saphenous nerve blockade described, however, in this chapter, we focus primarily on the one that we routinely use in our practice. With the patient in supine position, 5 to 10 mL of local anesthetic is injected as a ring deeply subcutaneously starting at the medial surface of the tibial condyle and ending at the dorsomedial aspect of the upper calf."

http://www.nysora.com/peripheral_ne...ock_tecniques/3080-saphenous_nerve_block.html


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## Davieda Skobel

Thanks for your help. The descriptions help a great deal.I also found good descriptions of the procedure but I'm wondering about modifiers, 59's on all three since they are for post op pain? Does anyone know if any insurance in any state would pay all three. These are being done in Louisiana.

Davieda


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## meganrveach

59 mods on the 64450 and 26 on the ultrasound if done in an ASC or hospital setting.


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## Davieda Skobel

*Popliteal and Saphenous Nerve blocks.*

Thanks to everyone for their input. I'll keep you posted as to who pays and who doesn't.


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## amieelyn2001

I am curious if you are getting these paid. We are in Louisiana as well and are having a lot of trouble getting more than one 64450 paid even with the 59- modifier and medical records to support both.


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## diane1217

I would advise you to check your state's Medicare LCD.  Medicare does not pay for these for post-op pain diagnosis since 11/25/11.    Bill 64450-59, 76942-26, 64450-59, 76942-26-59.


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## karras

Our BC/BS carrier won't pay for a second ultrasound even with a 59 modifier.  Does anyone know if you're actually getting paid for the second one?


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## dwaldman

3. CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

Above is from the NCCI policy manual. I am not sure if BCBS has a similiar policy


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