Neurosurgery Coding Alert

Do not limit yourself to 64405 and 64400.

Trigeminal and occipital nerve blocks for headache treatment are both common procedures for pain management specialists or neurologists. But do you understand the difference? Read on for the lowdown that will help you better understand your provider’s service.

When your physician treats a patient for occipital or trigeminal nerve pain, you’ll need to know what your physician does to treat the conditions and where exactly your physician inserts the needle. Follow this guidance and examples for accurate claims for occipital and trigeminal nerve procedures.

Starting point: Whether you’re reporting unilateral or bilateral blocks, you have one code choice for each type:

• 64405 – Injection, anesthetic agent; greater occipital nerve
• 64400 – Injection, anesthetic agent; trigeminal nerve, any division or branch.

Think ‘scalp’ for occipital injection: The greater occipital nerve (GON) originates from the C2 spinal nerve and provides sensory innervation to the posterior area of the scalp extending to the top of the head. Physicians typically inject the GON just above the base of the skull to treat occipital or cervicogenic headaches or neck pain. “These are typically unilateral posterior headaches and can be associated with numbness,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Think ‘face’ for trigeminal injection: In contrast, the trigeminal nerve -- also known as cranial nerve V or the fifth cranial nerve -- provides sensory innervation to most of the face. “It has three divisions which innervate the forehead, midface and jaw/chin,” Przybylski says.

Select Right Codes for Specific Occipital Nerves

In case of occipital neuralgia, your physician will perform a block in an office setting without any radiologic guidance.

You should code this as 64405. If the physician diagnoses lesser occipital nerve (LON) involvement, you report 64450 (Injection, anesthetic agent; other peripheral nerve or branch).

You have a limited number of codes for injections is specific peripheral nerves. CPT® does not assign a specific code for LON block procedure. Thus, you can best submit code 64450 for LON block.

The real challenge comes when your physician performs a block for the third occipital nerve (TON).

Best code for TON: You may report code 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) for the procedure on the TON.

Since location dictates your choice of code, you confirm that 64490 is a right code for the injection performed on the TON. Since the descriptor of code 64490 rightly defines the single level procedure of injection on the ‘paravertebral facet joint’, you would report this code for the TON injection procedures.

Code for Additional Procedures

If your clinician administered sedation to facilitate the procedure for occipital nerve injection, you would report code 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic 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).

Remember: You do not separately report the local anesthesia. Your clinician will administer local anesthesia into the overlying skin prior to administering the block. This helps to reduce the needle-track pain and ensures the patient is seated comfortably during the procedure. “This is consistent with other injection and surgical procedures,” Przybylski says.

Providing local anesthesia is included in the surgical procedure of TON. However, you can claim for reimbursement of the actual medication used for the actual block if your clinician bore the expense and performed the procedure in his office. You will need to check on your payer preferences for reimbursement of the medications. Typically, these medications have the suffix ‘caine’, e.g. lidocaine, mepivacaine, bupivacaine and/or ropivacaine. Medicare may deny the payment for these, while other payers may pay if you report J3490 (Unclassified drugs) for these blocks.

Target Anatomical Structures for Trigeminal Procedures

Review the operative note for specific details on where your surgeon created the lesion: in the trigeminal nerve, its ganglion or the nerve tract in the brainstem.

Your surgeon will commonly approach the gasserian ganglion to destroy the nerve cells so that the patient gets relief from pain. The ganglion is approached through the foramen ovale and the nerve cells are destroyed using chemical or electrical agents or radiofrequency.

When you are reporting percutaneous treatment of trigeminal neuralgia, you will need to choose from two codes, i.e. 61790 (Creation of lesion by stereotactic method, percutaneous, by neurolytic agent [e.g., alcohol, thermal, electrical, radiofrequency]; gasserian ganglion) and 61791 (Creation of lesion by stereotactic method, percutaneous, by neurolytic agent [e.g., alcohol, thermal, electrical, radiofrequency]; trigeminal medullary tract).

Just keep it simple. If the lesion is created in the brainstem, then you are going to use 61791, and if it is done in the gasserian ganglion, you will use 61790. The medullary tract is part of the brain stem and you can look for the term ‘medullary tract’ in the operative note to confirm that the surgeon worked in the brainstem.

Example: If the operative note mentions, “A percutaneous retrogasserian glycerol rhizotomy [PRGR] or percutaneous radiofrequency trigeminal gangliolysis (PRTG) was done,” you would report code 61790 as the procedures target the gasserian ganglion.

When trying to treat trigeminal neuralgia by doing a trigeminal tractotomy in the medulla, your surgeon will work at the level of medullospinal junction at the occiput-C1 level. The trigeminal tract is an eloquent target in trigeminal neuralgia. You report code 61791 for such procedures as it is clear that the trigeminal medullary tract and not the ganglion is being approached.

Watch the terminology: Providers may use different terms than “trigeminal” when noting the branch being injected, which could confuse coders; using an anatomy book can help you decipher the documentation. Use 64400 for injections to any of the three divisions or more distal branches including the supraorbital, the infraorbital, and the auriculotemporal nerve.