Eli's Rehab Report

Question: My physician prepared the suboccipital skin with isopropyl alcohol. He performed bilateral occipital nerve blocks in standard fashion and injected each side with 4.5 cc of 0.5 percent Marcaine and 20 mg of Depo-Medrol. The patient tolerated the injections well. Should I code this as 64405-RT and 64405-LT or code 64405 just once? Are occipital nerves considered bilateral?

Missouri Subscriber

Answer: Each payer processes this service differently, so you'll find a wide range of coding variations for the injection of the greater occipital nerve (GON). If your documentation clearly indicates two separate injections at separate anatomic locations, some payers request 64405 (Injection, anesthetic agent; greater occipital nerve) with -RT (Right side) and -LT (Left side) attached.

Others may prefer 64405 with modifier -59 (Distinct procedural service) attached to the second line item. And others may ask you to attach modifier -50 (Bilateral procedure). Some may process only one unit of 64405 for reimbursement no matter how it is coded.

Code 64405 has a bilateral indicator of "0," according to the resource-based relative value units from CMS. This means that bilateral services are not billable. This may be for two reasons: because anatomically this structure is not capable of being bilateral or you can find another code to encompass the bilateral service. However, you won't find a separate CPT code for the bilateral GON service versus unilateral.

Anatomy note:  There are two separate greater occipital nerves. Your physician can find each just lateral of midline on each side of the posterior scalp. Some providers perform one injection and then "flood" the area, which then blocks both greater occipital nerves.