ED Coding and Reimbursement Alert

Question: A patient reports to the ED reporting severe pain on the right side of her face. The ED physician performs a level-two E/M to discern the source of the pain, and diagnoses the patient with trigeminal neuralgia. The physician then performs a nerve block with tetracaine dissolved in bupivacaine, prescribes clonazepam and sends the patient home. Will insurers reimburse for a nerve block in this situation?

Texas Subscriber

Answer: They certainly should. Many patients with trigeminal neuralgia (also known as tic douloureux) require nerve blocks to alleviate symptoms associated with the condition. Just make sure your diagnosis coding reflects the patient's condition, and you should have no problem with acceptance.

On the claim, report the following:

• 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) for the nerve block.
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M.
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99282 to show the separate nature of the E/M and the block.
• 350.1 (Trigeminal neuralgia) appended to 64400 and 99282 to prove medical necessity for the services.

Remember: You don't necessarily need different diagnosis codes for a procedure and E/M on the same claim. If the same problem prompts both the E/M and the procedure, as in this case, the same ICD-9 code is allowable for both CPT codes.