Neurology & Pain Management Coding Alert

Hint: Home in on individual procedure steps to narrow options

With three occipital nerves in the body that your neurologist can treat to alleviate head and neck pain and many nerve injection codes to choose from in CPT, getting confused is easy when coding for third occipital nerve blocks. But you can code the procedures correctly once you have a good understanding of the procedure and the nerves involved.

Knowing Anatomy Can Help You Code Correctly

When your neurologist indicates that he performed an occipital nerve block, you may assume the procedure is 64405 (Injection, anesthetic agent; greater occipital nerve). But that's not always the case, says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. Physicians often administer injections to the third occipital nerve to help diagnose and differentiate forms and causes of headache and neck pain. Depending on what medications your physician uses, these injections can also be therapeutic, rather than just diagnostic, and used to relieve chronic headache and/or neck pain.

-The -third occipital nerve- is not anatomically synonymous with the -greater occipital nerve,-- Hammer says. -Physicians use both injections to diagnose and/or treat some forms of headache. But coding depends more on the anatomical structure and the needle insertion location than the patient's symptoms or diagnosis.-

Clarify sets: There are three separate and distinct pairs of occipital nerves in the body: the greater occipital, the lesser occipital, and the third occipital nerve (also occasionally referred to as the least occipital nerve). By reviewing your physician's documentation, you can identify which nerve he injected and assign the correct code for the procedure:

- The greater occipital nerve (GON) originates between the C1 and C2 vertebrae from the dorsal ramus/branch of the C2 spinal nerve. It primarily provides sensory cutaneous innervation to the scalp from the back of the skull to as far forward as the top of the skull. The GON also has some movement (motor) functions that innervate in the posterior neck muscles and sensory functions for the skin of the posterior scalp.

Physicians often inject the GON to diagnose and treat occipital neuralgia (723.8, Other syndromes affecting cervical region). The practitioner frequently performs the block in an office setting without the assistance of radiologic guidance. You should code it as 64405.

- The lesser occipital nerve (LON) also originates from the C2 spinal nerve, but its source is the ventral ramus/branch. It only has sensory functions that primarily innervate the skin behind the ear. Again, the provider usually administers this block in an office setting without radiologic assistance. CPT does not have a code specifically for the LON injection, so report it with 64450 (Injection, anesthetic agent; other peripheral nerve or branch).

- Finally, the third occipital nerve (TON) is the superficial medial branch of the C3 spinal nerve's dorsal ramus. It has both motor and sensory functions, like the greater occipital nerve. It innervates some of the neck muscles and is the primary sensory innervation for the C2-C3 facet joint. Pain stemming from this joint can be referred to the occiput and even as far as the frontal region and orbit.

Pinpoint the Correct Code

To establish a diagnosis and treat the patient's headache, your provider may inject each of the three occipital nerves. The practitioner determines which occipital nerve injection to use based on the patient's medical history and physical exam. Examples of supporting conditions include a history of neck trauma (whiplash) (847.0, Sprains and strains of other and unspecified parts of back; neck) or tender neck points (723.1, Other disorders of cervical region; cervicalgia), Hammer says.

If your neurologist blocks the TON at the C3 medial branch, where should you turn for coding, because 64405 and 64450 aren't correct? Some coders lean toward 64412 (Injection, anesthetic agent; spinal accessory nerve) because the TON is a sensory nerve. Code 64412 is not appropriate, however, because the spinal accessory nerve is the 11th cranial nerve and not synonymous with one of the three occipital nerves, Hammer says.

Better option: Instead, Hammer recommends coding TON blocks with 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level). Why? Because 64470 better describes the nerve location and needle insertion location.

Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C., agrees that 64470 may be the best code for TON blocks. -I would also append modifier 22 (Unusual procedural services) and include supporting documentation because the reimbursement for 64470 is not substantial enough for the level of risk involved with performing the injection,- she says.

Code All Parts of the Procedure

Patients usually go through a course of medication and physical therapy to treat their headache pain before the physician tries more aggressive treatments such as TON injections. But your physician may also conclude right away that an occipital nerve block would benefit the patient, depending on the patient's symptoms and chief complaint. These can include if the patient has consistent headaches (such as awakening with headaches and having continuous headaches all day for several days), Bukauskas-Vollmer says. The patient may also have migraines but usually has headaches caused by cervical sprain or strain and muscle spasms or deterioration.

When you code the block, Hammer says, remember the real-estate mantra: location, location, location. The needle injection location is your first clue for determining which occipital nerve your neurologist injected. Keep these clues in mind:

- An injection just off the midline at the back of the head is the greater occipital nerve

- An injection in the area behind the ear is most likely the lesser occipital nerve

- An injection of the C3 medial branch is the third occipital nerve.

Add other services: But when you-re coding, don't forget about other services that the neurologist often performs at the same session. These can include:

- 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) if he uses fluoroscopy with the TON block in the cervical region.

- 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) for injections in the other locations.

- 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic ortherapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time) for potential moderate sedation.

Don't count: Your neurologist will typically  anesthetize the skin prior to administering the block to help diminish needle-track pain, Hammer says. You won't code this local anesthetic injection separately, however, because it is included in the -surgical package definition- for the procedure.

Medication codes: The medication injected for the actual block is reimbursable if the neurologist bore the expense and he performed the procedure in his office. Physician preference and the patient's condition help determine the drug administered and its strength. Local anesthetic medications typically used for these blocks include what Hammer calls the -caines- (such as Lidocaine, Mepivacaine, Bupivacaine and/or Ropivacaine).

Caution: Medicare often denies the -caine- medications, but other carriers will sometimes pay for them, Bukauskas-Vollmer says. Some providers have better luck reporting J3490 (Unclassified drugs) for these blocks, so contact your local payers to learn their guidelines and follow accordingly.

Don't Overlook Follow-ups

Your neurologist might perform one type of block and have the patient return with a pain diary of results to determine the treatment's success. The patient's response to the block helps determine any subsequent treatment.

As with any procedure, complete documentation helps determine accurate coding and appropriate reimbursement.

-Understanding the anatomy of the procedure is a big help when coding for occipital injections,- Hammer says. -I urge providers to document specifics related to anatomic structures and needle location. This is for billing compliance as well as the two other reasons for good documentation: as a communication tool for other providers who might be treating the patient, and for medical/legal protection.

-I believe that specific documentation from the provider helps prevent the -assumptions- that coders attempt to make in abstracting codes from records with minimal detail.-