Neurology & Pain Management Coding Alert

ESI coding depends on approach.

When patients suffer from chronic or acute pain, other things in their lives often take a backseat. The intense pain can make even the most mundane tasks almost unbearably difficult.

Your PM provider will turn to medications and other conservative treatment methods to treat chronic pain. When that fails, however, they’ll often opt for interventional PM, a group of minimally invasive procedures to manage and treat pain.

These treatments cover a wide range of CPT® codes, and you need to know certain details to narrow your options down to the right one. Check out this advice on coding injections and nerve blocks for interventional PM patients.

Got Pain? Interventional PM Can Help

Patients needing interventional PM suffer distress and discomfort caused by a variety of conditions, including:

• Chronic head, mouth, and face pain
• Chronic low back and neck pain
• Muscle, bone, and/or nerve pain
• Malignancy

Patients reporting to a PM practice typically undergo a trial of different treatments to figure out which one will work best to combat their chronic pain. When the pain is severe enough to interfere with daily activities and cannot be managed through conservative treatments like physical therapy, exercise, or medication, the physician may turn to interventional PM techniques, such as injections and nerve blocks, to help make day-to-day activities less difficult.

Interventions Often Involve ESIs

One option is injections that may temporarily or permanently reduce the pain the patient is experiencing. Each of these injections target different pain spots in the body and typically include a numbing agent and a steroid. Common interventional`PM injections include epidural steroid injections (ESIs), transforaminal epidural injections, and facet joint injections.

ESI: The PM physician’s approach — interlaminar, transforaminal, caudal — is what differentiates the types of epidural steroid injections (ESIs). 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:

• 62320 (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; without imaging guidance)
• 62321 (… with imaging guidance (ie, fluoroscopy or CT))
• 62322 (… lumbar or sacral (caudal); without imaging guidance)
• 62323 (… with imaging guidance (ie, fluoroscopy or CT))

Example: If your PM doctor documents performing a caudal ESI with computed tomography (CT) for a patient with chronic low back pain, you’d report 62323 on the claim.

Transforaminal: During transforaminal epidural injections, the PM doctor inserts the needle between the spine and spinal cord, where the spinal nerve exits the spine, and injects the anesthetic agent and/or steroid in the space around the irritated nerve root. Look to codes such as the following to report transforaminal injections:

• 64479 (Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level)
• +64480 (… cervical or thoracic, each additional level …)
• 64483 (Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level)
• +64484 (… lumbar or sacral, each additional level …)

Facet joint: Your PM physician might opt for this type of injection if they determine the source of the pain is inflammation within a facet joint. This focused approach may provide relief for patients experiencing facet joint syndrome symptoms, including pain in the lower back, buttocks, or thighs. In such cases, according to Amy C. Pritchett, BSHA, CPC, CPCO, CDEI, CPMA, CPC-I, CRC, CANPC, CASCC, CEDC, CCS, CMDP, CMPM, CMRS, C-AHI, ICDCT-CM, ICDCT-PCS, past president of the AAPC local chapter in Mobile, Alabama, you should use the following codes:

• 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 …)
• +64492 (… third and any additional level(s) …)
• 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 ...)
• +64495 (… third and any additional level(s) …)

Nerve Knowledge Narrows Down Block Codes

Pain signals travel across nerves to the brain, and nerve blocks are used to interrupt these signals to provide pain relief. These blocks may be helpful for people who have low back pain, such as sacroiliac or facet joint pain, as the PM physician will block the nerve that gives the joint sensation, providing months of relief.

There is a multitude of codes for single-nerve blocks, as there are so many nerves in the human body. To narrow down the scope of single-nerve blocks that your PM provider might use, check out this list of commonly used codes:

Somatic nerves

• 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)

Autonomic nerves

• 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. You should always code each claim according to the notes you get from the performing provider.