Neurology & Pain Management Coding Alert

Interventional PM could involve several types of nerve blocks.

Patients reporting to the PM practice for pain management often undergo a trial of different treatments to figure out which one will work best for them.

While the PM provider searches for the best treatment course for that patient, they might use interventional pain management for short-term alleviation of pain. These treatments cover a wide range of CPT^® codes, including nerve blocks and pain pumps.

Take a look at the ins and outs of coding nerve blocks and pain pumps for interventional PM patients. In a future issue, we’ll take a look at how to code other interventional PM techniques.

Got Pain? Interventional PM Can Help

According to Amy C. Pritchett, BSHA, CPC, CPMA, CPCI-I, CRC, CANPC, CASCC, CEDC, CCS, CMDP, CMPM, CMRS, C-AHI, ICDCT-CM, ICDCT-PCS, past president of the American Academy of Professional Coders chapter in Mobile, Alabama, conditions interventional PM techniques commonly treat include:

• chronic headaches, mouth, or face pain;
• low back pain;
• muscle and/or bone pain; and
• neck pain.

While interventional PM is similar to prescriptions, physical therapy, and other methods to manage pain, interventional PM takes things a step further: It uses treatments such as nerve block and pain pump installation to address the pain.

So if conservative treatments for PM — such as pain management techniques attempted during an evaluation and management (E/M) service or physical therapy sessions— don’t work, interventional PM might be the next step.

ESIs Mark Top of Nerve Block/Injection List

Interventional PM is often realized via injections/nerve blocks, which send strong medication directly to the patient’s nerve to ameliorate the pain.

One of the most common interventional PM injections is an epidural steroid injection (ESI). According to Marilyn Torres, COC, CPC, CANPC, coding/billing supervisor at Meridian Medical Management in Belleville, New Jersey, you’ll report most ESIs with one of the following codes:

• 62321 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT))
• 62322 (Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance)
• 62323 (… with imaging guidance (ie, fluoroscopy or CT)).

So, let’s say the provider documents performing a caudal epidural nerve block with computed tomography (CT) for a patient with chronic low back pain. On the claim, you’d report 62323 for the block.

Providers Can Opt for Single-Nerve Blocks

Your provider might also choose to address the patient’s pain with a single-nerve block, if they can directly identify the nerve that’s causing the patient’s pain. There are a multitude of codes you can use to represent a single-nerve block, as there are so many single nerves in the human body.

In an effort to narrow down the scope of single-nerve blocks that your provider might use, check out this list of commonly used single-nerve block codes:

• 64400 (Injection(s), anesthetic agent(s) and/ or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)
• 64405 (… greater occipital nerve)
• 64418 (… suprascapular nerve)
• 64420 (… intercostal nerve, single level)
• 64425 (… ilioinguinal, iliohypogastric nerves)
• 64450 (… other peripheral nerve or branch)
• 64505 (Injection, anesthetic agent; sphenopalatine ganglion)
• 64510 (… stellate ganglion (cervical sympathetic))
• 64517 (… superior hypogastric plexus)
• 64520 (… lumbar or thoracic (paravertebral sympathetic)).

Note: This is not a complete list of interventional PM single-nerve blocks, nor is it an approved list of interventional PM techniques. You should always code each claim according to the notes you get from the performing provider.

Transforaminals Might Transform Pain

The PM provider might also use transforaminal injections to provide interventional PM. During these injections, the provider delivers an anesthetic agent or steroid into a single cervical or thoracic level via transforaminal epidural.

Aubre (West) Hansen, CPC, Aubre has a accountcoding supervisor, anesthesia and pain medical coder at EMMI Physician Services, Inc. in Lakewood, Colorado, reports that her practice provides the following transforaminal injections, along with several other interventional PM treatments:

• 64479 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level)
• 64480 (… cervical or thoracic, each additional level (List separately in addition to code for primary procedure))
• 64483 (Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level)
• 64484 (… lumbar or sacral, each additional level (List separately in addition to code for primary procedure)).

Provider Might Target Facet Joints

If the pain is more centralized in a facet joint, the provider might opt for a facet joint injections for interventional PM, Pritchett confirms.

• 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)
• 64491 (… second level (List separately in addition to code for primary procedure))
• 64492 (… third and any additional level(s) (List separately in addition to code for primary procedure))
• 64493 (Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level)
• +64494 (… second level (List separately in addition to code for primary procedure))
• +64495 (… third and any additional level(s) (List separately in addition to code for primary procedure)).

Pain Pump Might Be Prime Tx for Patient

Another option for interventional PM is pain pumps, also known as intrathecal pump implants. Once implanted, these pumps can deliver potent medications straight to the heart of the patient’s pain.

Pain pumps can be more effective because they provide a steady stream of pain relief, as opposed to the inconsistencies often associated with treating pain with oral medications or single-shot injections.

According to Pritchett, two of the most common pain pump procedures for interventional PM are 62350 (Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy) and 62351 (… with laminectomy).

Torres says she uses the following pain pump codes frequently to represent all phases of an interventional PM course of treatment:

• 62360 (Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir)
• 62361 (… nonprogrammable pump)
• 62362 (Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming)
• 62365 (Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion)
• 62367 (Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill)
• 62368 (… with reprogramming)
• 62369 (… with reprogramming and refill)
• 62370 (… with reprogramming and refill (requiring skill of a physician or other qualified health care professional)).

Warning: While the pain pumps might be more effective at providing interventional PM, this is a more involved and invasive procedure than E/Ms, epidurals, or nerve blocks. Therefore, you’re best off checking with each individual payer before reporting these codes. The payer might want proof that the provider attempted more conservative treatments for the patient’s pain before it will pay for a pain pump procedure.