Neurology & Pain Management Coding Alert

The agent the doc injects can give clues to proper coding

When coding injections or infusions of the lumbar spine, you should know two things before you begin: 1. Did the neurologist perform a nerve block or nerve destruction? 2. Which nerve did the neurologist target?

Follow these five tips to help you answer these questions and choose the right code.

1. Blocks Are Temporary

For nerve blocks, you can select from many codes in the 64400-64530 range. These procedures relieve back pain by anesthetizing the targeted nerve(s).

The neurologist may provide such services as a therapeutic measure (to increase patient comfort) or as a diagnostic tool (by numbing the nerves, the neurologist can pinpoint the source of the patient's pain and determine the underlying cause).

Common diagnoses supporting medical necessity for diagnostic blocks include 724.4 (Thoracic or lumbosacral neuritis or radiculitis, unspecified), 724.02 (Spinal stenosis, lumbar region), 722.10 (Displacement of lumbar intervertebral disk without myelopathy) and 724.3 (Sciatica).

Important: The purpose of the nerve block (therapeutic or diagnostic) will not affect your coding. That is, you would report a diagnostic nerve block and a therapeutic nerve block of a given nerve using the same code.

Although nerve blocks can provide permanent pain relief, as with reflex sympathetic dystrophy patients, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y., most nerve blocks provide only temporary relief.

2. Destruction Is Forever

For nerve destruction, look to the 64600-64681 series of CPT Codes (spinal codes are confined to 64622-64640). Unlike nerve blocks, nerve destruction - also known as denervation - permanently "kills" the nerve.

Nerve destruction is often one of the physician's last resorts for pain management after other techniques have failed, says Barbara Johnson, CPC, MPC, owner of Real Code Inc., a consulting firm in Moreno Valley, Calif.

"Most physicians would not perform neurolysis for trivial pain," Groudine says. "Once alcohol is put on a nerve, that nerve may never function again. Most people use it when the risk/benefit ratio favors extreme measures."

Conditions that may justify nerve destruction can include facet-mediated pain (724.8, Other symptoms referable to back), certain types of degenerative disk disease (from the 722.x series for Intervertebral disk disorders) and small herniated disk (such as spondylosis [721.3] or postlaminectomy syndrome [722.83] without radicular component or pain).

Continuous Infusion Is an Option

Keep in mind that nerve blocks can occur either by single injection or continuous infusion by catheter. The distinction matters when choosing the appropriate code(s).

Example: The neurologist provides a single injection for a nerve block to the sciatic nerve. The appropriate code is 64445 (Injection, anesthetic agent; sciatic nerve, single). If, however, the neurologist had targeted the same nerve via catheter infusion, the correct code is 64446 (... sciatic nerve, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration).

All continuous infusion codes - 64416 (brachial plexus), 64446, 64448 (femoral nerve), 64449 (lumbar plexus) and 64450 (other peripheral nerve or branch) - include both catheter placement and daily management for administering the anesthetic. Therefore, you should not code separately for these services.

3. Identify the Nerves Treated

When you've determined whether the neurologist administered a nerve block or performed nerve destruction, the next step is to determine the precise nerves the neurologist treated, as well as the method of introduction (injection, continuous infusion or epidural).

For low-back pain, the most likely block codes are:
 

Sciatic injection 64445
 

Continuous infusion of sciatic nerve (64446) and lumbar plexus (64449, Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter [including catheter placement] including daily management for anesthetic agent administration).
 

Facet injections 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) and +64476 (...lumbar or sacral, each additional level ...)
 

Transforaminal epidural codes 64483 (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level) and +64484 (... lumbar or sacral, each additional level ...)
 

Paravertebral injection 64520 (Injection, anesthetic agent; lumbar or thoracic [paravertebral sympathetic]).

Agent Doesn't Affect Coding for Destruction

The physician can choose from a variety of techniques for nerve destruction: chemical (injecting alcohol), thermal (using heat), electrical (using electrical stimulation) or radiofrequency (using heat to lesion a nerve to relieve pain).

Regardless of the method your neurologist chooses, however, your coding will not change.

Example: You would report destruction of a single lumbar facet joint using alcohol with 64622. For destruction using thermal techniques, you would still choose 64622.

The most common nerve destruction codes are: 

Neurolytic destruction codes 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) and +64623 (... lumbar or sacral, each additional level [list separately in addition to code for primary procedure]).

4. Turn to 50 for Bilateral Injections

 For facet injections 64475-64476, transforaminal epidurals 64483-64484 and destruction procedures 64622-64623, you may append modifier 50 (Bilateral procedure) if the doctor targets the nerve on both sides of the spine.

Bilateral claims will reimburse at 150 percent of the usual fee for a unilateral procedure, but documentation must support the claim by clearly identifying that the neurologist treated the nerve(s) on both sides of the spine.

Example: Because the facet joints are on either side of the vertebrae, physicians often perform bilateral facet injections. For instance, the neurologist may inject a steroid at the L3/L4 and L4/L5 joints, on both the right and left side. In this case, you should report 64475-50 and 64476-50.

Don't Forget Guidance With Facet Blocks

Remember, you can also charge separately for fluoroscopic guidance 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) with facet joint injections.

Report a single unit of 76005 regardless of the number of levels the neurologist injects.

5. Charge for Drug Supplies

You can often bill separately for the drug the neurologist injects, depending on the procedure, says Tonia Raley, CPC, claims processing manager for Medical Information Solutions in Phoenix.

Nerve block drugs can include anesthetics, anti-spasmodics, opioids or steroids/anti-inflammatories.

Physicians commonly use:  

Bupivacaine/Marcaine - S0020 (Injection, bupivacaine HCl, 30 ml)
 

Depo-Medrol - J1020, J1030 and J1040 (Injection, methylprednisolone acetate, 20 mg, 40mg and 80 mg)
 

Kenalog - J3301 (Injection, triamcinolone acetonide, per 10 mg). You will probably report J3490 (Unclassified drugs) for drugs not listed in HCPCS.

Bonus Tip: Agent Can Help Determine CPT Coding

One way to differentiate nerve blocks from destruction procedures is to pay attention to the agent the neurologist administers. For steroids or anesthetics, look to the nerve block codes. For neurolytic substances, such as alcohol, phenol or iced saline solutions, you should select a nerve destruction code.