Neurology & Pain Management Coding Alert

Question: My physician uses the diagnosis greater occipital neuralgia quite often, and I have not been able to find such a diagnosis in the ICD-9 manual, I have used others that come close but not an exact one. Which ICD-9 code should be used for this diagnosis?

Silvana Ferrer
Marina del Rey, Calif.

Answer: Arnold J. Weil, MD, a physician in private practice for eight years and a diplomat of the American Academy of Physical Medicine and Rehabilitation in Atlanta, says that in his experience, ICD-9 code 729.2 (neuralgia, neuritis, and radiculitis, unspecified) is the most commonly accepted for greater occipital neuralgia.

Bart W. Balint, MD, DABA, primary physician, neurologist and owner of Balint Pain Management Center in Weyers Cave, Va., and an associate of the American Pain Society, concurs with Weil. Balint adds that with occipital neuralgia, the problem occasionally can be tendonitis instead. That would be listed with ICD-9 code 726.90 (enthesopathy of unspecified site). Balint also says that an injection of the tendon would be coded 20550 (injection, tendon sheath, ligament, trigger points or ganglion cyst), the same as a trigger point injection. If an occipital nerve block is performed, the code would be 64405 (injection, anesthetic agent; greater occipital nerve).

If you had someone with an acute injury, you could code it for the acute neck sprain (847.0) and then more specifically occipital tendonitis or neuralgia, depending on what you felt best describes the condition, says Balint.

Weil adds that if an occipital nerve block is injected, a -50 modifier (bilateral procedure) should be attached to the 64405 provided the injection is done on both sides.

Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting, an independent consulting firm in Manassas, Va., suggests that before coding greater occipital neuralgia, a coder who is not a physician may find an understanding of the anatomy of the nerve helpful. The occipital nerves involve the upper cervical vertebrae at the base of the neck. Many coders incorrectly identify the occipital nerves as cranial nerves. In fact, the occipital nerves are peripheral cutaneous nerves. Peripheral nerves connect the brain or spinal cord with peripheral receptor or effectors.

The greater occipital nerve is distributed in the muscles of the back and neck and the skin over the occiput, and its function is motor and sensory. The lesser occipital nerve is a sensory nerve that is distributed in the skin behind the ear and on the back of the scalp and originates from C2 and C3. The occipital third is distributed in the skin of the back of the head and nape of neck and originates from C3. A patient suffering from occipital neuralgia may experience a spot of tenderness between the mastoid process (the projection of a portion of the temporal bone at the side of the skull that is the attachment of various muscles) and the upper cervical vertebrae (C2-C3).

Coding this type of neuralgia is difficult. First, you would search the ICD-9 manuals alphabetic index under the main term neuralgia, neuralgic, looking for the subterm or essential modifier for occipital, which would prove unhelpful. When this occurs, use the code that is listed with the main term, in this case 729.2 (neuralgia, neuritis, and radiculitis, unspecified).

Because this is an unspecified code, you may wish to look under different main terms in the index. When originally searching under the main term neuralgia, the instructional note of see also disorder, nerve appears often. Looking under this term, the subterm occipital again would not be found, but under the subterm nervous system NEC is code 337.9 (unspecified disorder of autonomic nervous system). When comparing the two codes to see which one is more specific to the diagnosis, 729.2 represents disorders of soft tissues while 337.9 refers to disorders of the autonomic nervous system. Query the physician which code best represents the diagnosis.

Note: Occipital neuralgia is more of a symptom and usually occurs with an underlying condition. If so, code the underlying condition or a more definitive diagnosis if it is known.