Pain Management Coding Alert

Question: Our pain management specialist documented “0.5 ML across the right and 0.5 ML across the left supra orbital and supratrochlear and infraorbital nerves. All are part of ophthalmic division.” Coding for trigeminal nerve blocks confuses me because the trigeminal nerve is also the fifth cranial nerve. How should I code this? 

Montana Subscriber 

Answer: First, know that part of the information documented is not correct. Not all three of the branches mentioned are from the V1 ophthalmic nerve. The infraorbital nerve is a branch of the V2 maxillary nerve. 

The correct code for injections of the divisions and/or branches of the trigeminal nerve (Cranial nerve V) is 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch). This particular cranial nerve has three divisions referred to as V1 (ophthalmic nerve), V2 (maxillary nerve), and V3 (mandibular nerve).  Each of the divisions has multiple nerve branches (such as V1 includes the supratrochlear and supraorbital nerves). 

According to CPT® Assistant in December 2008, “The descriptor of code 64400 represents a single injection into a single nerve in the anatomy and sensory distribution of the peripheral trigeminal nerve. Injection of each specific nerve has effects on different anatomy sensation in different areas. The code 64400 is considered to be unilateral and when performed bilaterally can be reported as such.”  

Modifier note: Many Medicare contractors require providers to use an alternate modifier to indicate a repeat procedure and only use modifier 59 (Distinct procedural service) when appropriate. 

If your physician performed a total of six separate injections (the right and left supratrochlear nerves, right and left supraorbital nerves, and right and left infraorbital nerves), you have two coding options: 

• 64400-50 (Bilateral procedure) x 3 OR
• 64400-50 x 1 and 64400-50-76 (Repeat procedure or service by same physician or other qualified health care professional) x 2.

If the forehead area was only injected twice – once for right side and once for the left – blocking both the supratrochlear and supraorbital branches with a single injection, the coding would be:

• 64400-50 x 2 OR
• 64400-50 x1
• 64450-50 – 76 x 1.

Verify the number of injections to each nerve before submitting the claim.