# Need Help - Can somone help me code this please



## Thooks0627 (Aug 12, 2013)

Can somone help me code this please:   

Dr. Notes:

  Patient came in for occipital nerve block for occipital and trigeminal nerve block and trigger point injections, indicated for intractable and recurring migraine headaches, associated with trigeminal and occipital neuralgia, also cervicalgia with trigger points and muscle spasm.  The patient reports her previous set of treatments in December 2012 was very helpful, but symptoms are starting to recur.  The patient was evaluated and was found to have tenderness to light pressure over the bilateral supraorbital, anterior auricular, and occipital nerve insertion points, with pressure eliciting dysesthesias along each ipsilateral nerve territory; the patient also had eight identified trigger points, at the bilateral upper cervical paraspinals (C2-C3); the bilateral mid cervical paraspinals (C4-C5); and the bilateral lower cervical paraspinals (C6-C7); and the medial trapezius ridge.  

The risks and potential benefits of nerve block and trigger point injections were discussed with the patient, who voiced understanding and gave verbal consent.  A total of 1 cc of Kenalog (40 mg) and 5 cc of 0.5% bupivacaine solution were combined.  Using a sterile 30-gauge needle, approximately 0.5 cc of this mixture was delivered over the bilateral supraorbital nerve insertion points and the bilateral auricular nerve insertion points.

Using a sterile 27-gauge needle, approximately 0.5 cc of this mixture was delivered over the bilateral occipital nerve insertion points, and the remainder was delivered in equal proportions to each of the trigger points listed above.  

There was no blood loss, there were no complications, and the patient tolerated the procedure well.

Thanks
Tanya


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## dwaldman (Aug 14, 2013)

Below is what NCCI check yields that I ran thru the Supercoder site:

Code 20552 is a column 2 code for 64400 , but a modifier is allowed in order to differentiate between the services provided.
*Use modifier with code 20552
CCI edit Rule:
More extensive procedure

Code 20552 is a column 2 code for 64405 , but a modifier is allowed in order to differentiate between the services provided.
*Use modifier with code 20552
CCI edit Rule:
More extensive procedure

Code 20552 is a column 2 code for 64450 , but a modifier is allowed in order to differentiate between the services provided.
*Use modifier with code 20552
CCI edit Rule:
More extensive procedure

____________________________________________________________________
I ran the NCCI check considering the Occipital nerve block performed at bilateral insertion points would be represented by CPT 64405 with the 50 modifier as described in the following:

"delivered over the bilateral occipital nerve insertion points, "

For CPT 64400 with the 50 modifier given I am reading it clearly and there where two separate injections (does refer to as injection points in the plural form) the following would represent 64400-50

"approximately 0.5 cc of this mixture was delivered over the bilateral supraorbital nerve insertion points "

For the trigger point injections, I selected for the cervical paraspinals and trapezius ridge muscles I selected only two muscles as 20552. Maybe someone more familiar with the anatomy could relay if this would constitute more than two separate muscles . I was just going by name. It appears these are a in separate anatomical areas as the other injections and you could add the 59 modifier appropriately. 

For the part of the procedure note that states: 
bilateral auricular nerve insertion points.

I was thinking this was 64450-50 but I was kind overwhelmed with which nerve it fell under as seen below there are different ones that similar to select so I guess my suggestion for your coding scenario would be the following in RVU sequence. This is the best I could determine and other forums members might indicate there could be errors in this suggestion.

64400-50
64405-50
64450-50
20552-59

http://medical-dictionary.thefreedictionary.com/auricular+nerve,+great


auricular nerves, anterior  origin, auriculotemporal nerve; distribution, skin of anterosuperior part of external ear; modality, general sensory.

auricular nerve, great  origin, cervical plexus—C2–C3; branches, anterior and posterior branches; distribution, skin over parotid gland and mastoid process, and both surfaces of auricle.

auricular nerve, posterior  origin, facial nerve; branches, occipital branch; distribution, posterior auricular and occipitofrontal muscles and skin of external acoustic meatus; modality, motor and general sensory.

auriculotemporal nerve  origin, by two roots from the mandibular nerve; branches, anterior auricular nerve, nerve of external acoustic meatus, parotid branches, branch to tympanic membrane, and branches communicating with facial nerve; its terminal branches are superficial temporal to the scalp; distribution, parotid gland, scalp in temporal region, tympanic membrane; modality, general sensory.


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