Neurology & Pain Management Coding Alert

Hint: Coding depends on the block's purpose

When your neurologist treats diabetic neuropathy, he might administer some type of block to relieve the patient's pain. Because CPT includes many coding options for blocks, be sure you know the reason behind the specific treatment before completing your claims.

Area and Type of Pain Start Treatment Planning

Once a patient comes to your physician, her actual treatment depends on the specific area affected and the type of pain she has. These factors -- plus the patient's pain threshold and how she reacts to medications -- determine how often the neurologist administers treatments, says Barbara Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif.

Treating entrapment: Your physician might administer corticosteroid injections to treat entrapment neuropathies. If so, report the service with the appropriate neuroplasty code from 64702-64726 (codes related to Neuroplasty; Neuroplasty, major peripheral nerve, arm or leg; Neuroplasty and/or transposition; and Decompression), depending on which nerve he treats.

Your neurologist might also administer nerve blocks to temporarily interrupt the impulse conduction in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions.

Determine the Pain Source

Diagnostic blocks help identify the source of the patient's pain and the type of nerve that conducts the pain (i.e., pinpoint a nerve that acts as a pathway for pain). Diagnostic blocks also help show whether the pain generates from the central or peripheral nervous system, which helps your physician determine the best pain relief treatment options. 
 
How it works: The physician can inject saline to stimulate pain or inject an anesthetic agent to evaluate the patient's response, says Susan West, CPC, a coder and auditor with Auditing for Compliance and Education in Leawood, Kan.Code carefully: Coding a diagnostic nerve block can be tricky because CPT does not include a code specific to the procedure. Your best option might be 90779 (Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion) since it's a diagnostic procedure.

Another option: Johnson says many coders tend to consider 64450 (Injection, anesthetic agent; other peripheral nerve or branch) when the neurologist treats diabetic neuropathy. Some carriers might question this, however, because the physician injects saline during the procedure instead of an anesthetic agent. Check with your carriers about coding these diagnostic blocks.

Treat the Pain With the Correct Block

Therapeutic blocks treat painful conditions that might respond to nerve blocks. When your neurologist administers a therapeutic block, you have the opposite problem from coding for a diagnostic block: now you have many coding choices rather than none.

When coding for therapeutic nerve blocks, first determine whether the neurologist performed an injection to a particular site or administered a neurolytic. Common coding options for these situations include: 

- 64400-64450 -- Injection, anesthetic agent to various somatic nerves

- 64470-64476 -- Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve

- 64479-64484 -- Injection, anesthetic agent and/or steroid, transforaminal epidural

- 64505-64530 -- Injection, anesthetic agent to various sympathetic nerves.

Check a Treatment's Success

Prognostic blocks predict the outcome of long-lasting interventions such as infusions, neurolysis or rhizotomy. Report these blocks with the appropriate code for nerve destruction by a neurolytic agent, depending on the type of nerve, treatment site and injection level.

Code somatic nerve destruction with:

- 64600-64610 -- Destruction by neurolytic agent, trigeminal nerve

- 64612-64614 -- Chemodenervation of muscle(s)

- 64620 -- Destruction by neurolytic agent, intercostal nerve

- 64622-64627 -- Destruction by neurolytic agent, paravertebral facet joint nerve

- 64630-64640 -- Destruction by neurolytic agent.

Report sympathetic nerve neurolytic destruction with either 64680 (Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus) or 64681 (- superior hypogastric plexus), based on which nerve your neurologist destroys.

Code rhizotomy with 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) or 64626 (- cervical or thoracic, single level), depending on the injection site.

Because the patient continues seeing her endocrinologist or primary-care physician for other aspects ofdiabetes care, work with that physician to ensure you code your neurologist's services correctly. Some carriers might deny claims if multiple physicians caring for the patient use the same diagnosis code.
 
Final note: When you-re coding for a patient's diabetic neuropathy treatment, you also need to watch details such as whether the visit qualifies as a consult or referral, the type of pain the patient has, and the appropriate diagnosis choices. For more on these coding considerations, see -Double-Check Diagnoses for Diabetic Neuropathy to Avoid Denials- in the February 2007 issue of Neurology Coding Alert.