# Need help sorting out injections (chart note included)



## ollielooya (Aug 26, 2009)

Here is the following chart note that accompanies an E/M visit: BILATERAL OCCIPITAL NERVE BLOCK/TRIGGER POINT INJECTIONS 

_Patient was consented for bilateral occipital nerve blocks and trigger point injections.  A solution containing 4.5-cc of 2% Lidocaine, 4.5-cc of 0.5% Sensorcaine,  and 1.0 cc of Kenalog (40 mg) for a total of 10-cc was prepared in a 10 CC syringe. Two syringes containing the same solution were prepared.  

Target areas in the suboccipital region were identified via palpation and pain response.  The trigger sites were marked. The occipitocervical junctions were sterilized with alcohol wipes. The contents of each syringe was injected in a fanlike fashion on each side. 

The headaches essentially resolved and she still had pain on the left  occipitocervical junction.  The trigger site was identified and marked.  A solution containing 2.5 mL of 0.5% Marcaine and 2.5 mL of 2% Lidocaine was prepared. The trigger site was injected. The occipital headaches resolved.   

Patient tolerated the procedure well and no complications were noted. 

Patient was monitored and discharged in stable condition.  Patient had a driver. 
At a time of discharge, the vitals were  xxx/xx, xx
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code choices:  99214, 64400-50, 64405-50, 51, 64400-50,51, 96372, and accompanying  J codes.  My question concerns the 96372 in this particular case.  Because the nerve blocks were bilateral, the TWO injections are considered bundled into the procedures, correct?  I could still bill for the 3rd injection with a 59?  How shall the 96372's be notated?  Therefore, do I just include ONE unit of 96372 with modifer 59?  Or do I bill for the 2 units of 96372 (knowing it will be bundled), and 1 unit on a separate line with 59?  Thanks for helping me before.  About the time I think I'm getting the idea, hesitation settles in.  
Suzanne, CPC-A_


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## Walker22 (Aug 27, 2009)

I see several problems with this coding scenario.

1. I do not see documentation for 64400 (trigeminal block) at all.
2. Since 64405 is an injection by definition, then 96372 is automatically bundled and should not be billed.
3. 64405 already includes an office visit, as all surgical codes do. Unless there was more work done by the provider that was not listed in the post, a separately identifiable office visit is not warranted.

64405-50 plus the J codes seems to be the appropriate billing to me.


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## ollielooya (Aug 27, 2009)

I did not include all the chart notes, and of course the presentation of initial codes were not substantiated by this partial submission.  I apologize.  My thoughts were that for THIS particular chart note, there was that EXTRA injection and didn't know if this would be separately billable with modifier 59.


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## Walker22 (Aug 27, 2009)

I would code as follows:

99214 - 25
64400 - 50 (bilateral trigeminal block)
64405 - 50, 51 (bilateral occipital block)
64405 - LT, 76 (repeat left occipital block)
+ the associated J codes.

I still don't think the 96372 applies.


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## MMAYCOCK (Aug 31, 2009)

*Need help  on coding*

We are having a bit of confusion on how to code the following: Can someone help with this? I would like to know how it should be coded in both the physician office and the ambulatory surgery setting if possible. Thank you!
*OPERATIVE REPORT:*
_Facet joint intra-articular injection at (L3-4, L4-5 and L5-S1 levels bilaterally), along with associated medial branch blocks After risks and benefits were reviewed, consent was obtained. The patient was taken back to our surgical suite and laid in the prone position. The mid back was sterilely prepped and draped in a typical fashion. The vitals were monitored throughout the entire procedure. Under flouroscopy, strict aseptic conditions, local anesthesia and standard protocols, mid back over the maximum axial tenderness is identified and coorelated with imaging study and levels of pain producing facet joint were identified , and selected lumbar facet joints were injected at (L3-4, L4-5 and L5-S1 levels bilaterally) is performed with (10 mg) of Methylprednisone along with 2cc of 1% Lidocaine at each of these levels. During injection of the medication patient's axial pain appeard to be reproduced. (Isouve-200, contrast dye was used to localize the intra-articular joint and to make sure that there is no spread of the medication intra-vascularly or intraduraly). Patient tolerated the procedure well._

It was coded with only two levels, but I believe it should be three. Our physician went to a seminar and was told to always subtract a level. Thank you!!!!


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## Walker22 (Aug 31, 2009)

MMAYCOCK said:


> We are having a bit of confusion on how to code the following: Can someone help with this? I would like to know how it should be coded in both the physician office and the ambulatory surgery setting if possible. Thank you!
> *OPERATIVE REPORT:*
> _Facet joint intra-articular injection at (L3-4, L4-5 and L5-S1 levels bilaterally), along with associated medial branch blocks After risks and benefits were reviewed, consent was obtained. The patient was taken back to our surgical suite and laid in the prone position. The mid back was sterilely prepped and draped in a typical fashion. The vitals were monitored throughout the entire procedure. Under flouroscopy, strict aseptic conditions, local anesthesia and standard protocols, mid back over the maximum axial tenderness is identified and coorelated with imaging study and levels of pain producing facet joint were identified , and selected lumbar facet joints were injected at (L3-4, L4-5 and L5-S1 levels bilaterally) is performed with (10 mg) of Methylprednisone along with 2cc of 1% Lidocaine at each of these levels. During injection of the medication patient's axial pain appeard to be reproduced. (Isouve-200, contrast dye was used to localize the intra-articular joint and to make sure that there is no spread of the medication intra-vascularly or intraduraly). Patient tolerated the procedure well._
> 
> It was coded with only two levels, but I believe it should be three. Our physician went to a seminar and was told to always subtract a level. Thank you!!!!



Two levels is correct.... The devil is in the fine print of the description of the CPT code 64475. They are coded per level, not per nerve. It takes 2 nerves to innervate each level (one at the top and one at the bottom). So it takes the nerve at L3L4 AND the nerve at L4L5 to innervate the L4 spinal level. Therefore, in the above example, the levels that were done were L4 and L5. There was an article in one of the Coding Edge magazines during the last year or so dealing with exactly this issue, it can explain it way better than I just did!


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## marvelh (Sep 1, 2009)

I don't see the documentation for the trigeminal nerve injection. 

The actual procedure documentation is not clear as to what was injected - only that the needles were inserted at the occipitalcervical junction.  This is not the typical needle insertion site for a Greater occipital nerve (GON) injections, which is usually at the superior nuchal ridge (higher than the documented needle placement).  From the documentation provided, it appears that the provider injected trigger points rather than perhaps a GON nerve block "...the trigger sites were marked....the trigger site was identified and marked...the trigger site was injected..."

If that is the case, trigger point injections are coded based on the number of muscles injected: 20552 for 1 - 2 muscles OR 20553 for 3 or more muscles.  This would most likely be 20552 as the documentation does not specifically identify 3 or more muscles.

IF the provider actually did inject the GON bilaterally, those 2 injections would be reported with 64405 - 50 x 1.

IF the provider injected the GON bilaterally at the occipitocervical junction and injected a trigger point at the same occipitocervical junction as documented, the code would remain as 64405-50 x 1 as the trigger point injection code (20552) is bundled by CCI edits into the 64405 code.  The edit can be bypassed with a modifier if the trigger point injection was performed in a different anatomic site (not as documented) or a different session (not as documented).  So per the documentation provided, it would not be appropriate to bypass the edit with the 59 modifier.

I would check back with your provider for clarification and perhaps an addendum to the procedure note.


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