Pain Management Coding Alert

Question: A patient presented with a bi-occipital headache with associated tenderness radiating to the bifrontal regions of the head. Her signs and symptoms were consistent with occipital neuralgia. The physician decided to administer bilateral greater and lesser occipital nerve blocks. Procedure documentation states: 1.5 mL of 40 mg/1 mL of Kenalog mixed with 1.5 mL of 2% Lidocaine was injected in the following manner – 1.5 mL in the right and left greater occipital nerve region and 1.5 mL in the right and left lesser occipital nerve region.

The other neurology biller and I do not agree on how to code J3301. Can you share your opinion?

Florida Subscriber

Answer: Based on the documentation, the physician injected 1.5 mL of 40 mg/mL of Kenalog, or a total of 60 mg (1.5 x 40). Kenalog is also known as triamcinolone acetonide. Code J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) is based on 10 mg for each unit of service, so 60 mg would be billed as J3301 with 6 units of service.