Anesthesia Coding Alert

Follow these 4 tips for trigeminal and GON success.

If you code for pain management services, two of the most common nerve injections you’ll see your provider administer are to the trigeminal and greater occipital nerves (GON). Injections to these nerves can help relieve pain caused by multiple conditions, which is why they’re so common. They also can be easily confused by coders, so learning to differentiate between the injections will help you choose the best diagnosis code to support medical necessity.

Expert advice: Read on for practical tips on coding these nerve injections from Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE Inc. in Overland Park, Kansas.

Tip 1: Begin With 64400 for Trigeminal Injection

If encounter notes indicate that the patient received a trigeminal nerve injection, report 64400 (Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)).

“The trigeminal nerve is one of the 12 cranial nerves and provides sensation to the face as well as various facial muscular functions such as chewing,” Blaszczyk explains. “The nerve runs from the skull, branching into three divisions that supply feeling to the forehead [ophthalmic], the cheek [maxillary], and the lower jaw [mandibular].”

For pain relief, a branch of the trigeminal nerve is injected with a combination of local anesthetic and steroid.

Tip 2: Expect a Trigeminal Neuralgia Diagnosis

Patients who need a 64400 service often suffer from, appropriately enough, trigeminal neuralgia.

“Trigeminal neuralgia, also called tic douloureux, is a nerve disorder that frequently causes shooting pain to one side of the face in one or any combination of the three areas mentioned above,” Blaszczyk says. “The pain attacks can occur on both sides of the face but not at the same time, and they typically worsen over time, occurring more frequently. Minor stimulation, such as a slight breeze or touching the cheek could precipitate an attack.”

The ICD-10 code you’ll report for trigeminal neuralgia is G50.0 (Trigeminal neuralgia).

Another condition that lends itself to a 64400 service is herpes zoster (or shingles), which is “caused by a latent chickenpox virus in the patient, that due to age, an underlying disease process, an acute illness, or other stressor may then reactivate, causing a variety of neurologic manifestations,” says Blaszczyk.

Sometimes, the attack is acute; when this occurs, report diagnosis B02.9 (Zoster without complications) for the shingles.

Other times, “the pain from the acute attack may be long lasting and is called post-herpetic trigeminal neuralgia,” says Blaszczyk. When this occurs, code the shingles with B02.22 (Postherpetic trigeminal neuralgia).

Note: These are only examples of patient conditions that might warrant a trigeminal nerve injection. You should always code to the notes and choose the appropriate codes based on the encounter form. Don’t be surprised, however, if you see one of the above conditions manifest itself in a patient who requires trigeminal nerve injection.

Tip 3: Remember GON Injections Target Another Nerve

Another common nerve injection that your provider might perform is a GON injection, which you’d report with 64405 (Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve).

“The back of the head and the most upper part of the neck would be considered the anatomical locations involved with the greater and lesser occipital nerves. The greater occipital nerve supplies sensation to the skin over the posterior skull, including the occiput and temporal areas, and to the vertex and ear,” explains Blaszczyk.

Tip 4: Look for Occipital Neuralgia with 64405

Pain in the greater occipital nerve is occipital neuralgia, which you’d report with M54.81 (Occipital neuralgia). This diagnosis will likely be a consideration with some GON injection patients.

“Occipital neuralgia is characterized as persistent pain at the base of the skull with occasional sudden shock-like paresthesias in the distribution of the greater and lesser occipital nerves. The area is typically also tender to palpation and may be associated with trigger points in the same area,” explains Blaszczyk.

Your provider might also use GON shots to treat other headache syndromes, including:

• G43.- (Migraine)
• G44.- (Other headache syndromes)
• G45.- (Transient cerebral ischemic attacks and related syndromes)
• R51.- (Headache)

Note: Like above, these are only examples of patient conditions that might warrant a GON injection. You should always code to the notes and choose the appropriate codes based on the encounter form.