# Multiple intercostal nerve blocks



## b10sliger

MD dictates that injection was done at the inferior aspect of left T4 rib...this was repeated at left T5, T6, T7 intercostal level.  Everything we can find dictates that only 3 units may billed at a time.  Any suggestions?


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## dwaldman

For multiple nerves treated with mulitple injections you bill 64421 with quantity one. It is not per injection

Below is CPT Assistant article and lay description from Encoder

Ignenix Encoder
The physician anesthetizes the intercostal nerve to block chest wall pain. In 64420, a single injection is performed. In 64421, multiple nerves are injected to provide pain relief to a larger area (regional block). 


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CPT Assistant November 2010

Surgery: Nervous System

Question:If a single injection is performed for a thoracic intercostal nerve block, the effect of which is to block multiple intercostal nerves, it is appropriate to report CPT code 64421,Injection, anesthetic agent; intercostal nerves, multiple, regional block,or is the provider limited to re-
porting code 64420,Injection, anesthetic agent; intercostal nerve, single?

Answer:From a CPT coding perspective, “single injection” means “single nerve block.” Therefore, code 64420 should be reported. If only one needle is placed into the skin but manipulated up and down to inject into more than one nerve, it may be possible to report multiple blocks (code 64421). However, from a clinical perspective, blocking multiple intercostal nerves with a single injection is hard to do in most settings.


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## millortsui

64421 which is for multiple


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## susie59

*more on 64421 & 64420*

I am still a little confused over these codes and would appreciate more guidance.  T8/9/10/11/12 were all injected.  What would be the proper coding?  Would 64421 be used for the first level followed by 64420 with a modifier?  Would 64420 be billed more than once?  Thank you for your help with this.


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## dwaldman

64421 is reported once to represent multiple intercoastal nerves blocked.
64420 is reported once if only a single intercoastal nerve is blocked.
If performed bilateral,  modifier 50 or RT and LT could be used.


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## phukriede

64421(Intercoastal nerve, each additional level) is listed on the 2020 CPT book as an add on code, therefore, it cant be used by itself. 64421 would need to be reported in addition to the primary procedure, which in this case is 64420.


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## Melissa Harris CPC

2020 CPT guidelines changes for intercostal nerve blocks.  64420 is the primary procedure and 64421 is the add on code per injection level.   

"left T4 rib...this was repeated at left T5, T6, T7 intercostal level." would be billed 64420 LT  64421 x 3 LT


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## suec

Hope you don't mind me jumping on this thread.  Has anyone coded a cryoablation of intercostal nerves?  My surgeon did a VATS with cryoablation & intercostal nerve block.  Lung was dissected from the chest wall, cryoablated 6 intercostal levels.  Levels 5,6,7,8,9,10.  Afterwards injected at the same sites bupivacaine & depo-Medrol.   My think was 64620 or 04427 or 64999.   64420 & 64421 x5  is an injection.  Any suggestions.


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## dwaldman

AMA CPT Assistant November 2019
Question: Is it appropriate to report code 64620 for a cryoablation procedure performed on an intercostal nerve after a minimally invasive Nuss bar repair of pectus excavatum? 

Answer: No, it is not appropriate to report code 64620, Destruction by neurolytic agent, intercostal nerve. Code 21743, Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy, is the only code that should be reported. The cryoablation procedure is for pain control, which is considered inherent to the global surgical package. Some third-party payers may request that these services be reported differently. Therefore, contact your local thirdparty payers directly for specific reporting guidelines.+


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## dwaldman

AMA CPT Assistant April 2019
Also, the addition of Category III codes 0440T-0442T in 2017, which address percutaneous cryoablation with imaging guidance, generated additional questions regarding the applicability of code 64640 (see codes 0440T-0442T and their descriptors): 
0440T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/ peripheral nerve
0441T lower extremity distal/peripheral nerve
0442T nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)


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