Neurology & Pain Management Coding Alert

Question: What is proper billing for a right third occipital nerve block with a C2-C3 intra-articular facet injection? Will we need to include modifier 22 because of the additional work? 

Arizona Subscriber

Answer: The appropriate procedure code is 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). 

As noted in the descriptor, you bill 64490 “per level.” C2-C3 is a single level, so you’ll only report 64490 once. Include modifier RT (Right side) since the provider injected the nerve on the right side. 

Anatomy refresher: The third occipital nerve (TON) is the superficial medial branch of the C3 spinal nerve’s dorsal ramus. It innervates the C2-3 facet joint as well as some of the muscles in the neck and back of the head. Pain stemming from this joint can be referred to the occiput and even as far as the frontal region and orbit.

The purpose of the C2-C3 facet joint injection ultimately is to block the third occipital nerve fibers innervating the facet joint. Therefore, you typically only submit 64490 and won’t need to append modifier 22 (Increased procedural service).