# cpt for superficial dermatomal injection



## diane1217 (Mar 9, 2010)

Need help with pain management.  Doc did "multiple superficial dermatomal injections" for postherpetic neuralgia.

OP report:  The area over the left thoracic wall and axillary area was marked as the most senstivite area of postherpetic neuralgia symptoms.  Using a 22-gauge spinal needle, 0.25% Marcaine w/ epinephrine in combination w/ methylprednilosone was injected throughout the area involved subcutaneously for a total of 26mL of solution.  All needles were removed intact.

Conflicted betwen coding a sub-q injection (93672) or regional intercostal nerve block (64421) or what???

ANY comment greatly appreciated,
Diane


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## miriamwebb (Mar 9, 2010)

*Answer to your coding question*

I would choose the sub-q code.  The injection was done subcutaneously as stated in the note. 

MK


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## blonde01 (Mar 10, 2010)

diane1217 said:


> Need help with pain management.  Doc did "multiple superficial dermatomal injections" for postherpetic neuralgia.
> 
> OP report:  The area over the left thoracic wall and axillary area was marked as the most senstivite area of postherpetic neuralgia symptoms.  Using a 22-gauge spinal needle, 0.25% Marcaine w/ epinephrine in combination w/ methylprednilosone was injected throughout the area involved subcutaneously for a total of 26mL of solution.  All needles were removed intact.
> 
> ...



96372 is a component of 64421.  You shouldn't bill for the Anesthetic; only bill for cortosteroids (J codes).  

Authoratative Documentation from CMS:

Medicare Part B Local Coverage Determination

"CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply."

Contractors Determination Number: *AC-03-041 *

Contractor Name: Medicare Services  

Contractor Number: 00520, 00524, 00528 

Contractor Type: Carrier 

LCD Title: Intercostal Nerve Blocks/Neurolysis 

AMA CPT Copyright Statement: "CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply." 

CMS National Coverage Policy: Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary. 
Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim. 
Title XVIII of the Social Security Act, section 1862(a)(7) excludes routine physical evaluations. 


Primary Geographic Jurisdiction: 00520 - Arkansas
00524 - Rhode Island
00528 Louisiana 

Secondary Geographic Jurisdiction: Not applicable 

Oversight Region: Region I Boston (RI) Region VI Dallas (AR, LA) 

CMS Consortium: Northeast (RI) Southern (AR, LA) 

DMERC Region LCD Covers: Not applicable 

Original LCD Effective Date: 10/01/2006 (RI) 04/15/2004 (AR, LA, MO, NM, OK) 

Revision Ending Date: 02/29/2008 (NM, OK) 
05/31/2008 (MO) 
04/30/2009 (RI) 

Indications and Limitations of Coverage and/or Medical Necessity: Chronic neuralgic pain secondary to an injured intercostal nerve(s) as a result of rib fracture, a thoracotomy incision or the chronic pain due to post herpetic neuralgia or chronic pain secondary to benign or malignant processes. 

Type of Bill Code: Not applicable 

Revenue Codes: Not applicable 

CPT/HCPCS Codes: This policy does not take precedence over the Correct Coding Initiative (CCI). Consult current correct coding guidelines for applicable specific code combinations or reductions in payment due to specific codes billed. 

The following short descriptors are in accordance with the AMA copyright agreement. Please refer to the current CPT book for full descriptions. 
64420 N block inj, intercost, sng 
64421 N block inj, intercost, mlt 
64620 Injection treatment of nerve 

ICD-9 Codes that Support 
Medical Necessity:
 053.10 Herpes zoster with unspecified nervous system complications 
053.13 Postherpetic polyneuropathy 
053.14 Herpes zoster myelitis 
195.1 Malignant neoplasm of thorax 
338.0 Central pain syndrome 
338.11-338.19 Acute pain 
338.21-338.29 Chronic pain 
338.3 Neoplasm related pain (acute)(chronic) 
338.4 Chronic pain syndrome 
353.8 Other nerve root and plexus disorders 
724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 
733.6 Tietze's disease 
807.00-807.09 Rib(s), closed fracture 
807.4 Flail chest 
998.9 Unspecified complication of procedure, not elsewhere classified 

Diagnosis that Support Medical Necessity: Not applicable 

ICD-9 Codes that DO NOT Support Medical Necessity: Not applicable 

Diagnosis Codes that DO NOT Support Medical Necessity: Not applicable 

Documentation Requirements: 1. Medical necessity for performing the procedure must be clearly documented in the medical records. 
2. Claims must be submitted with appropriate diagnosis information, such as ICD-9-CM codes coded to the highest level of specificity.  

Utilization Guidelines:   

Sources of Information and Basis for Decision: 1. Satterhwaite, Dollison. Handbook of Pain Management, 2nd Edition, 1994, Williams and Wilkins. 
2. Yale University School of Medicine, Department of Pain Management. 
3. Connecticut Society of Anesthesiology. 
4. Local Medical Policy from Nationwide Insurance Company, Louisiana, and Arkansas. 
5. Medicare Operations Spine Five: 1980; 193 200. 
6. Journal of Neurosurgery 1975;43:448-451. 
7. Joint section on pain, the American Association of Neurological Surgeons and Congress of Neurological Surgeons. 
8. American Pain Society. 

Advisory Committee Notes: The Arkansas consortium combined LCD was presented in December 2003 (AR, LA, MO, NM, OK) and March 2006 (RI) and accepted. 

"This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from all recognized specialties within the state."  

Start Date of Comment Period: 03/15/2006 (RI) 11/17/2003 (AR, LA, MO, NM, OK) 

End Date of Comment Period: 04/30/2006 (RI) 01/15/2004 (AR, LA, MO, NM, OK) 

Start Date of Notice Period: 08/15/2006 02/29/2004 (AR, LA, MO, NM, OK) 

Revision History:   
04/06/2009 PBSI Part B policy retired in Rhode Island due to workload transition to J14 MAC contractor (NHIC). 
05/31/2008 PBSI policy retired in Missouri due to workload transition to J5 MAC contractor (Wisconsin Physicians Services). 
02/29/2008 PBSI policy retired in New Mexico and Oklahoma due to workload transition to J4 MAC contractor (Trailblazer Health Enterprises, LLC). 
07/11/2006 Added ICD-9 codes 053.14, 338.0, 338.11-338.19, 338.21-338.29, 338.3, and 338.4 due to the 2007 coding update (CR5142) and effective 10/01/2006. 

Policy revised to include Rhode Island (00524). This policy was presented to the RI CAC on 03/22/2006, released on 08/15/2006 in the August 2006 newsletter, and effective with DOS 10/01/2006. 
03/01/2006 Deleted ICD-9-CM code 053.14. This code was published in the 2006 ICD-9-CM book but was not approved and is not valid. 
01/11/2006 Added new 2006 ICD-9 code 053.14 to allow effective 10/01/2005. This codes was new in 2006 ICD-9 book but was not included in CR for annual release. 
12/01/2005 Reformatted to LCD. Added CCI statement to HCPCS/CPT section.


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## cswan (Mar 10, 2010)

*Sub-q vs nerv inj*

I would agree with using Sub-q injection CPT 96372, as that's what the note describes- no mention of nerves in the note.  I'd also add the J code for the steroid if this was an in-office injection-drug supplied by the MD (vs facility). The Coder's Desk Reference states that for a 64420 'the physician anesthetizes the intercostal nerve..' and in 64421 'multiple nerves are injected...'.  Many nerve injections from pain management providers utilize fluoroscopic guidance to ensure they get to the correct nerve site.  If you have any question about whether or not a nerve was injected, query the provider.
Hope this helps...

Cindy L. Swan, CPC


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## hgolfos (Mar 11, 2010)

Nicely put Cindy.  I agree, you only use the Jcodes if your provider is supplying the meds.


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