Neurology & Pain Management Coding Alert

Our 4 questions will point you to the best diagnosis and injection codes.

If your neurologist or pain specialist administers greater occipital nerve blocks, don't let coding turn into a headache. Verify specifics about the patient's headache and the service your provider offered to pinpoint the correct diagnosis and procedure codes every time.

Where Is the Occipital Nerve?

The greater occipital nerve (GON) originates from the posterior medial branch of the C2 spinal nerve and provides sensory innervations to the posterior area of the scalp extending to the top of the head. Physicians typically inject the GON at the level of the superior nuchal line just above the base of the skull for occipital headaches or neck pain.

Tip: Some physician practices include a small illustration in the chart that the physician can mark with various injection sites. Including this type of tool helps your physician clearly document the injection location, which helps you choose the correct nerve injection code and submit more accurate claims.

What Type of Headache Does the Patient Have?

Your physician's documentation might include notes ranging from "occipital headache" to "occipital neuralgia" to "cervicogenic headache." Your job is to ensure that you interpret the notes and assign the most accurate diagnosis.

Occipital headache: ICD-9's alphabetic index does not include a specific listing for occipital headache. Because of this, report the general code 784.0 (Headache), which includes "Pain in head NOS." More details in your provider's notes might lead to diagnoses such as 307.81 (Tension headache), 339.00 (Cluster headaches), 339.1x (Tension type headache), or 346.xx (Migraine).

Occipital neuralgia: You have a more specific diagnosis to code when your provider documents occipital neuralgia. Greater occipital neuralgia produces an aching, burning, or throbbing pain or a tingling or numbness along the back of the head. You'll report diagnosis 723.8 (Other syndromes affecting cervical region).

Cervicogenic headache: "The alphabetic index doesn't include a listing directing coders to review a specific ICD-9 code," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. Many coders report 784.0 (Headache) for lack of a better option.

Which Service Did the Provider Perform?

Physicians can choose to treat occipital nerve pain by administering a nerve block or eventually by ablating the nerve.

Nerve block: Administering a nerve block temporarily relieves the patient's pain. For a greater occipital nerve block, report 64405 (Injection, anesthetic agent; greater occipital nerve). Some insurance companies classify 64405 as experimental or investigational, so these might deny coverage. Review coverage policies so you know what to expect when filing your claim.

Nerve destruction: When more conventional treatments fail to provide long term pain relief, the physician might opt for nerve destruction. Whether you see the term "radiofrequency ablation" or "thermocoagulation" on the patient's chart, you have two code choices, depending on where the physician performed the destruction. If he performed RF destruction at the terminal end of the nerve, report 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). If he performed RF at the origination, submit 64626 (Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level). Verify, however, that your provider destroyed the nerve instead of treating it with pulses. The pulsed treatment doesn't appear to destroy the nerve, which eliminates 64640 and 64626. Instead, pulsed treatment falls under 64999 (Unlisted procedure, nervous system).

How Do You Handle Bilateral Injections?

When your provider administers bilateral GON injections, verify the patient's insurance company before completing your claim.

Here's why: Most Medicare contractors want you to report bilateral procedures as a single line item with a single unit of service and modifier 50 (Bilateral procedure) appended. Private payers, however, often require two lines for bilateral claims:

• Line 1 with the procedure code, modifier RT (Right side), and one unit of service
• Line 2 with the procedure code, modifier LT (Left side), and one unit of service.

Remember that Medicare reimburses bilateral procedures at 150 percent of the allowed amount. That means you'll receive 100 percent reimbursement for the first injection and 50 percent reimbursement for the second injection.