Neurosurgery Coding Alert

Question: My physician performed three bilateral nerve blocks: a lesser occipital nerve block, a greater occipital nerve block, and a supraorbital occipital nerve block. Do these procedures require three separate codes? If so, are they each billable together? Also, can you bill these procedures using a migraine diagnosis?

Wisconsin Subscriber

Answer: These three procedures all require individual codes and can be alongside one another. There is some confusion in the coding community when it comes to differentiating between greater and lesser occipital nerve blocks, and additionally how they relate to supraorbital nerve blocks. Let’s take a look at these three procedures from an anatomical perspective:

• The greater occipital nerve is located at the medial branch of the dorsal portion of the C2 spinal nerve. This nerve provides innervation to the scalp along the top of the head, the area above the ears, and the area over the parotid glands.
• The lesser occipital nerve begins at the lateral branch of the ventral area of the C2 and C3 spinal nerves. This nerve is tasked with innervating the area of the scalp and head posterior to the ears.
• The supraorbital nerve is a sensory branch of the frontal nerve. This nerve exits the orbit through the supraorbital foramen (or notch) and is responsible for innervating the forehead, scalp, upper eyelid, and frontal sinus.

When one of these nerves malfunctions, the result is an excruciating pain that the provider typically treats with a nerve block (anesthetization of the nerve).

As for coding, we will apply these three nerve block CPT^® codes for the lesser occipital, greater occipital, and supraorbital nerve blocks, respectively:

• 64450, Injection, anesthetic agent; other peripheral nerve or branch
• 64405, Injection, anesthetic agent; greater occipital nerve
• 64400, Injection, anesthetic agent; trigeminal nerve, any division or branch

You will also be appending modifier 50 (Bilateral procedure) to all three procedure codes due to the documentation of bilateral nerve blocks.

Correct Coding Initiative (CCI) edits do not report any circumstances in which these three procedures bundle together; therefore, they are appropriate to bill out separately without the use of a differentiating modifier.

This last question regarding a migraine diagnosis is where a provider will find trouble, however. A simple local coverage determination (LCD) lookup will reveal that no ICD-10 code relating to a migraine is covered for any of these three procedures. If this is the only diagnosis on file, you will need to send the report back to the physician to determine if any additional diagnosis exists that is a covered diagnosis per the Medicare LCD.