Neurology & Pain Management Coding Alert

Learn about nerve structure to help ensure correct codes

Understanding the facial nerve structure and paying attention to all possible treatments the patient might have will help you submit correct claims for your neurologist's services when he treats trigeminal neuralgia.

Understand What's Happening

The trigeminal nerves provide all sensation to the face, teeth, mouth, sinuses, meninges (coverings of the brain) and blood vessels of the head. And trigeminal neuralgia (also known as tic douloureux) is an extremely painful condition affecting the face.

A trigeminal nerve is on each side of the head, with each separating into three branches. Patients feel trigeminal pain in the area reached by one or more of these branches in the upper, middle or lower part of the face. Trigeminal neuralgia usually occurs on one side of the face, although some patients experience it on both sides of the face at the same time.
 
-In essence, this is a disorder of the fifth cranial nerve, or trigeminal nerve,- says Franz Ritucci, MD, director of the American Academy of Ambulatory Care in Orlando, Fla. -It produces severe pain episodes that may last for seconds or minutes. Patients have numerous attacks--sometimes hundreds--a day.-

Deep, burning pain may continue between the jolts or may disappear. Even simple activities such as chewing, talking, shaving or having cold wind blown on the face can trigger the attacks. 

Look to MRI, CT, MRA as Diagnostic Tests

Ruling out other pain-causing conditions (such as a neoplasm between the cerebellum and pons) is one of the first steps toward diagnosing trigeminal neuralgia. Physicians often rely on MRI (magnetic resonance imaging), CT (computed tomography) or MRA (magnetic resonance angiogram) scans to assess the patient's condition.

Neurologists usually send patients to a radiology facility for MRI, CT and MRA tests. Keep the procedure codes in mind, however, because you might report them with modifier 26 (Professional component) if your physician interprets the results:

- 70551 (Magnetic resonance [e.g., proton] imaging, brain [including brain stem]; without contrast material), 70552 (- with contrast material[s]) or 70553 (- without contrast material, followed by contrast material[s] and further sequences) for MRI

- 70450 (Computed tomography, head or brain; without contrast material), 70460 (- with contrast material[s]) or 70470 (- without contrast material, followed by contrast material[s] and further sections) for CT

- 70544 (Magnetic resonance angiography, head; without contrast material[s]), 70545 (- with contrast material[s]) or 70546 (- without contrast material[s], followed by contrast material[s] and further sequences) for MRA.

In most situations, physicians say MRI is a better diagnostic tool than a CT scan. Conducting an MRI with and without contrast is the best option, says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside.
 
Other options: The neurologist might also conduct a facial EMG (95867, Needle electromyography; cranial nerve supplied muscle[s], unilateral; or 95868, - cranial nerve supplied muscles, bilateral) or evoked potential test (95927, Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head) to help diagnose trigeminal neuralgia.

Watch for Meds, Then Blocks as Treatment 

Fortunately, physicians have many options for treating trigeminal neuralgia. First-line treatment often includes medication such as baclofen, divalproex sodium, carbamazepine, phenytoin, pregabalin or clonazepam.
 
The neurologist usually administers these treatments on an outpatient basis. Report the service with the appropriate outpatient E/M code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient -) for a new patient or 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient -) for an established patient.

But many patients fail to find pain relief with medications alone, Ritucci says. That means they move on to more aggressive treatments, which might include:

- Trigeminal nerve blocks: Nearly half of patients with trigeminal neuralgia have nerve block treatments (64400, Injection, anesthetic agent; trigeminal nerve, any division or branch). These blocks usually consist of tetracaine dissolved in bupivacaine, Ritucci says.

- Radiofrequency neurolysis: During this treatment, the physician heats the affected nerve with a focused microwave, keeping it from transmitting pain signals. Code the procedure based on which nerve the neurologist treats: 64600 (Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch), 64605 (- second and third division branches at foramen ovale) or 64610 (- second and third division branches at foramen ovale under radiologic monitoring). Technique note: The physician can either use a pulse technique to temporarily stop the nerve function and alleviate pain, or permanently destroy the nerve. You should code the procedure the same, regardless of the neurologist's treatment technique.
 
- Radiofrequency thermocoagulations: The physician uses heat to destroy the affected nerve during this procedure. Report it as radiofrequency neurolysis, with the appropriate choice from 64600-64610. 
 
- Cryoneurolysis: Cryoneurolysis--or freezing the affected nerve to relieve pain--is a good treatment for trigeminal neuralgia initially, but patients often experience relapse. If your neurologist performs cryoneurolysis, choose a code from 64600-64610.

Final treatment steps: Last-resort options for trigeminal neuralgia treatment might be surgical procedures such as microvascular decompression, trigeminal rhizotomy or gamma knife radiosurgery. The neurologist refers the patient to a neurosurgeon at this point for additional care.