Neurology & Pain Management Coding Alert

Chest pain can often lead to PVB.

Patients who report to your PM clinic suffering from thoracic or abdominal pain will often require a nerve block. When these blocks are necessary, your provider will often perform either a transverse abdominus plane (TAP) block or a paravertebral block (PVB).

As a coder, it’s up to you to figure out which type of block the provider performs. You can do this by recognizing the particulars of both blocks on encounter forms and developing a sharp eye for conditions that might warrant a TAP block or PVB.

To get top-flight info on these blocks, we asked Toni Elhoms, CCS, CRC, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer, chief executive officer of Alpha Coding Experts, LLC, in the Orlando, Florida area; and Kelly D. Dennis, MBA, ACS-AN, CAN-PC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Florida. Here’s what they had to say.

Rib Breaks Point to PVB

When you are reporting a PVB, you’ll select from the following codes, as appropriate:

• 64461 (Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed))
• +64462 (… second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure))
• 64463 (… continuous infusion by catheter (includes imaging guidance, when performed))

According to Elhoms patients that would need PVBs include “those undergoing mastectomies, cosmetic breast procedures, thoracic surgery — and also patients that have suffered rib fractures.”

Common conditions associated with these procedures include complex regional pain syndrome (CRPS) I, chest pain, chest trauma, neuralgia, and rib fractures, according to Elhoms.

Some of the more common diagnoses that might accompany a PVB include:

• G89.11 (Acute pain due to trauma) through G90.59 (Complex regional pain syndrome I of other specified site)
• M79.2 (Neuralgia and neuritis, unspecified)
• R07.1 (Chest pain on breathing) through R07.9 (Chest pain, unspecified)
• S22.31XA (Fracture of one rib, right side, initial encounter for closed fracture) through S22.49XB (Multiple fractures of ribs, unspecified side, initial encounter for open fracture)

Note: This is only a list of ICD-10 codes that might prove medical necessity for a PVB. It is not an exhaustive or approved list of diagnoses, and you should always code to the encounter notes when reporting any and all diagnoses and CPT^® codes.

Check Out This Clinical Example

Elhoms also provided an example of a PVB encounter that you might see at your practice:

A 55-year-old male presents with severe chronic thoracic pain due to lung metastasis. Patient was resting lateral decubitus with the side to be blocked in the uppermost position, the spinous processes are marked on the skin and a parasagittal line is measured and drawn lateral to the midline. The subcutaneous tissue and paravertebral muscles are infiltrated with local anesthetic along the parasagittal line. Using visual and tactile landmarking and ultrasound imaging as indicated, a spinal needle with extension tubing attached to the syringe containing local anesthetic is inserted into the T3-T6 paravertebral space and the anesthetic is injected. Patient received PVB injections at T3-T6.

Coding: For this encounter, Elhoms says you’ll report 64461 for the first injection site and +64462 for the subsequent injection site. Also append G89.3 (Neoplasm related pain (acute) (chronic)) and C78.00 (Secondary malignant neoplasm of unspecified lung) to 64461 and +64462 to represent the patient’s diagnoses.

TAP Block Typically Relates to Abdominal Issues

When your provider performs a TAP block, it is typically for acute pain management related to abdominal surgery, Dennis explains. When you are reporting a PVB, you’ll select from the following codes, as appropriate:

• 64486 (Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed))
• 64487 (… by continuous infusion(s) (includes imaging guidance, when performed))
• 64488 (Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed))
• 64489 (… by continuous infusions (includes imaging guidance, when performed))

According to Elhoms, patients that might need TAP blocks include “patients undergoing postoperative pain control in abdominal procedures, including:

• “large bowel resection,
• “open/laparoscopic appendectomy,
• “cesarean section,
• “total abdominal hysterectomy,
• “laparoscopic cholecystectomy,
• “open prostatectomy,
• “renal transplant surgery,
• “abdominoplasty with/without flank liposuction,
• “iliac crest bone graft, and
• “inguinal hernia repairs.”

The TAP block is also effective for procedures in which epidural analgesia is contraindicated (e.g., anticoagulated patients), states Elhoms.

According to Dennis and Elhoms, ICD-10 codes that you might see on a TAP block include:

• G89.18 (Other acute postprocedural pain)
• G89.28 (Other chronic postprocedural pain)
• R10.8- (Other abdominal pain)

Or you might also use a combination of G89.18 and R10.8, Dennis relays.

Note: This is only a list of ICD-10 codes that might prove medical necessity for a TAP block. It is not an exhaustive or approved list of diagnoses, and you should always code to the encounter notes when reporting any and all diagnoses and CPT^® codes.

Check Out This Clinical Example

Consider this example of a TAP block, courtesy of Elhoms:

A patient reports to the practice for postop pain management. The patient recently underwent exploratory laparotomy, sigmoid colectomy with takedown of enterovesicular fistula, and a colostomy. The provider performed a bilateral TAP block by injections for postop pain by injecting a local anesthetic in the space between the aponeurosis of the internal oblique and transversus abdominis muscles to anesthetize the nerves that supply the anterior abdominal wall (T6-L1).