Neurology & Pain Management Coding Alert

Site of needle insertion is your key to select the right code.

When your neurologist treats occipital neuralgia, you'll need to identify which nerve was treated and the insertion site. Read on to learn how to identify the correct nerve injected and to code it appropriately.

Strengthen Your Occipital Anatomy Basics

You will come across three distinct sets of occipital nerves in the body, so you'll need to know which one in specific your physician is treating. To get to the right code, you should know the origin of the nerves, the structures these nerves supply and their distribution, and the common complaints due to involvement of these nerves in any pathology.

Identify nerve pathology: One common condition stemming from the involvement of the GON that you will often need to report is the occipital neuralgia. You report ICD-9 code 723.8 (Other syndromes affecting cervical region) for occipital neuralgia.

Note: When ICD-10 goes into effect, you'll report M54.81 (Occipital neuralgia) for this distinct type of headache.

You should look for conditions like neck trauma (whiplash) (847.0, Sprains and strains of other and unspecified parts of back; neck) or tender neck points (723.1, Other disorders of cervical region; cervicalgia) in the procedure note to ascertain the cause of the headache for which your physician administered the injection. "The clinical history will often reveal focal trauma directly to the nerve region and on examination, patients will often describe unilateral numbness in the distribution of the nerve," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Select Right Codes for Specific Nerves

In case of occipital neuralgia, your physician will likely perform a block in an office setting without any radiologic guidance. You should code this as 64405 (Injection, anesthetic agent; greater occipital nerve). If the physician diagnoses LON involvement, your physician may also perform a block for the LON without radiological assistance. You will then report 64450 (Injection, anesthetic agent; other peripheral nerve or branch).

"Currently, the codes for these two injections are not bundled together by Medicare's 18.0 NCCI edits. If your physician injects the GON and LON on the same date of service, it would not be necessary to append a modifier such as -59 (Separate procedure) when billing these two CPT® codes together." says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. CPT® does not assign a specific code for LON block procedure. "CPT® includes only a limited number of codes for injecting specific peripheral nerves. If one is not specified, like LON, then code 64450 is applied," says Przybylski.

The real challenge comes when your physician performs a block for the TON.

Best code for TON: You may report code 64490 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level) for the procedure on the TON if the injection is performed at the C2-C3 spinal level.

Tip: The TON is neither anatomically nor functionally synonymous with the GON. Look carefully in the procedure notes what necessitated the physician to perform the block and where the needle was inserted for the procedure. Your physician may perform the block on any of the three different occipital nerves to either diagnose or treat the patient's headache. Your physician should record the medical history and clinical examination to narrow down the choice to block a particular occipital nerve.

Find Needle Insertion Site

Read in the procedure note to identify where your physician inserted the needle. This is going to be your prime clue to choosing the right code.

Examples: If you read in the procedure note that your physician inserted the needle near the midline at the back of the head, you will likely be reporting an injection for the GON. Similarly, an injection behind the ear is your hint for an LON procedure. If you read that the injection was given in the medial branch of C3, you report the procedure for TON. "Only the injection of the TON requires image-guidance, which may also help you differentiate when a C2-3 paravertebral facet joint nerve is performed," says Przybylski.

Report 64490 for the Third Occipital Nerve

Since location dictates your choice of code, you should confirm with the physician that 64490 is a right code for the injection performed on the TON. Since the descriptor of code 64490 rightly defines the single level procedure of injection on the 'paravertebral facet joint', you would report this code for the TON injection procedures.

Tip: Never use 64412 (Injection, anesthetic agent; spinal accessory nerve) to report the injections in the TON. Whereas TON is a sensory nerve, the spinal accessory nerve is the 11th cranial nerve. Hence, code 64412 does not correspond with the TON procedure.

Code for Additional Procedures

If your clinician administered sedation to facilitate the procedure for the occipital nerve injection, you could potentially report code 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time).

Remember: You do not separately report the local anesthesia. Your clinician will administer local anesthesia into the overlying skin prior to administering the block. This helps to reduce the needle-track pain and ensures the patient is seated comfortably during the procedure.

Providing local anesthesia is included in the surgical procedure of TON. However, you can claim for reimbursement of the actual medication used for the actual block if your clinician bore the expense and performed the procedure in his office. You will need to check on your payer preferences for reimbursement of the medications. Typically, these medications have the suffix 'caine', e.g. lidocaine, mepivacaine, bupivacaine and/or ropivacaine. Medicare may deny the payment for these, while other payers may pay if you report J3490 (Unclassified drugs) for these blocks. You report HCPCS code J2001 (Injection, lidocaine HCl for intravenous infusion, 10 mg) for lidocaine, the commonest local anesthetic your physician may use.

Hammer says, "Remember the CPT® Section Guidelines for Moderate (Conscious) Sedation services require that the level of sedation is moderate, not minimal or deep sedation nor monitored anesthesia care. The physician should also document the total amount of moderate sedation intraservice time as these codes are time-based codes and require meeting the mid-point threshold of time."

Report Bilateral injections: You should report for injections on both sides when your physician injects nerves bilaterally. "All of the occipital nerves are considered to be unilateral, e.g. if a physician injects both the right LON and the left LON, injections of the "mirror-image" nerves would be coded as bilateral by appending modifier 50 to the CPT code. All of the CPT® codes reported for the different occipital nerve injections, i.e. 64405, 64450 and 64490, can be billed as bilateral procedures." says Hammer.