Neurology & Pain Management Coding Alert

Although neurologists frequently use paravertebral and facet joint nerve blocks as a non-invasive way to relieve chronic pain and forestall surgery, nerve blocks also can be used for diagnostic purposes. But properly coding these procedures is not always clear.

For example, if a physician is considering a differential diagnosis such as intercostal neuralgia (353.8), nerve blocks may be needed to establish the exact diagnosis. Or if the origin of a patients pain is unclear, as in the case of leg pain following a spinal cord injury, a nerve block quickly can locate the source of the pain.

The biggest mistake in seeking reimbursement for nerve blocks is trying to code bilaterally, says Devona Slater, CMCP, president of Ace Auditing for Compliance and Education in Leewood, KS. Slater is the author of Prescription for Pain Billing, and serves as a compliance auditor with a specialty in pain management issues.

The thing that people do wrong is that they think the right and left each constitutes an increased service level, and they dont, says Slater. Just because you go on the right side and the left side, thats not an increased service level. The spine is not bilateral. For example, if a neurologist gives injections for nerve blocks in both legs, each leg would be reimbursed as a separate procedure, or in some cases, coded as a bilateral procedure. For spinal nerve blocks, however, injecting on each side does not constitute an additional level of service.

In addition, neurologists should not use modifier -50 (bilateral procedure) or the RT/LT modifiers (right or left) with nerve blocks. Each level requires both a right and left component. These two injections count as one procedureone nerve block.

Another Problem: Multiple Injections

Also, carriers often reject billings for multiple injections at different sites on the same day, regardless of medical necessity, says Brenda Mitaro, billing manager for Neurology and Pain Management of Palm Beach in Jupiter, FL. This practice often uses nerve block injections for patients with headaches, cervical problems and occipital neuralgia.

For multiple injections, Mitaro says that modifier -76 (repeat procedure) works for occipital neuralgia. For other conditions, Mitaro uses modifier -59 (distinct procedure) for multiple injections and finds that some carriers will accept it.

Nerve blocks are covered by two pairs of codes. Paravertebral nerve blocks as well as single vertebral level blocks are covered by 64440. A second code, 64441, is for multiple levels or a regional block.

Only two ICD-9 codes support medical necessity for 64440 and 64441: 723.4 (brachial neuritis or radiculitis) and 724.4 (thoracic or lumbosacral neuritis or radiculitis, unspecified, generally used to indicate the presence of radicular syndrome of the lower limb).

A related procedure, paravertebral facet joint nerve block, is covered by 64442, while 64443 indicates additional levels. Neurologists generally use this procedure when facet joint pain is suspected in patients with back pain without a strong radicular component.

Covered diagnosis codes for facet joint nerve blocks include:

720.1 spinal enthesopathy
721.2 thoracic spondylosis without myelopathy
721.3 lumbosacral spondyosis without myelopathy
721.42 spondylosis with myelopathy, lumbar region
721.90 spondylosis, unspecified site, no myelopathy
722.71-722.73 intervertebral cervical disc disorder
with myelopathy
722.81-722.83 post-laminectomy syndrome
723.1 cervicalgia
724.00 spinal stenosis, unspecified region other than cervical
724.01 spinal stenosis, thoracic region
724.02 spinal stenosis of lumbar region
724.09 spinal stenosis, other region, other than
cervical
724.1 pain in thoracic spine
724.2 lumbago
724.3 sciatica
724.8 other symptoms referable to back

Some neurologists use fluoroscopic guidance when placing the needle at the facet joint. In this case, they are eligible for additional reimbursement. Although there is no specific code for fluoroscopic guidance, most carriers will accept 76499 (unlisted radiological procedure).