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Eli's Rehab Report

Reporting 64405 for Third Occipital Nerve Blocks? Think Again

Published on Tue Jul 01, 2003

Physiatrists who administer third occipital nerve blocks should not automatically assume that 64405* (Injection, anesthetic agent; greater occipital nerve) is the most appropriate code. Most coding consultants recommend reporting 64470-22 instead of 64405 to more accurately describe these types of blocks.

Occipital Nerves Differ

When a physician indicates on the charge ticket that he or she performed an occipital nerve block, your instinct might tell you to assign 64405. But 64405 is not always the most accurate code, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. Physiatrists administer injections to the third occipital nerve to help diagnose and treat different forms of headache and neck pain.
 
"The 'third occipital nerve' is not anatomically synonymous with the greater occipital nerve," Hammer says. "Physicians use both injections to diagnose and/or treat some forms of headache. But coding depends more on the anatomical structure and the procedure location than the patient's symptoms or diagnosis." 
 
The body contains three different sets of occipital nerves: the greater occipital, the lesser occipital, and the third occipital nerve (also referred to as the "least occipital nerve"). By reviewing the physiatrist's documentation, you can identify which nerve he or she blocked and assign the correct code for the procedure.
 
The greater occipital nerve originates from the dorsal ramus of the C2 spinal nerve. It has movement (motor) functions that innervate in the posterior neck muscles and sensory functions for the skin of the posterior surface of the scalp. Physicians often inject the greater occipital nerve to diagnose and treat occipital neuralgia (723.8, Other syndromes affecting cervical region). You should report 64405 for this procedure.
 
The lesser occipital nerve also originates from the C2 spinal nerve, but its source is the ventral ramus. It has only sensory functions that innervate the skin behind the ear. When blocking this nerve, you should report 64450* (Injection, anesthetic agent; other peripheral nerve or branch). 
 
The third occipital nerve (TON) is the superficial medial branch of the C3 spinal nerve's dorsal ramus. The TON, like the greater occipital nerve, has both motor and sensory functions. It innervates some of the neck muscles and the C2-3 facet joint. Pain stemming from this joint can be referred to the occiput and even as far as the frontal region and orbit.

Pinpoint the Correct Code

A physiatrist may inject all three occipital nerves to help diagnose or treat chronic headaches. The practitioner selects the appropriate occipital nerve injection based on the patient's medical history and condition (for example, a history of neck trauma such as whiplash [847.0, Sprains and strains of other and unspecified parts of back; neck], tender neck points [723.1, Other disorders of cervical region; cervicalgia], description and quality of headache, etc.), Hammer says.
 
If the physician blocks the TON, some coders erroneously report 64412* (Injection, anesthetic agent; spinal accessory nerve) because the third occipital is a sensory nerve. This code is not appropriate, however, because the spinal accessory nerve is one of the 12 cranial nerves, and not one of the three occipital nerves, Hammer says.
 
Instead, she recommends coding TON blocks with 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) because it describes the nerve location better.
 
Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C., agrees that 64470 may be the best code for TON blocks. "I would also append modifier -22 (Unusual procedural services) and include supporting documentation because the reimbursement for 64470 is not substantial enough for the level of risk involved with performing the injection," she says.

Location, Location, Location!

When you report TON blocks, Hammer says, remember the mantra of real estate location, location, location. The block's needle location should be your first clue when determining which occipital nerve the provider injected. Keep these clues in mind: A C2 dorsal injection is the greater occipital nerve, a C2 ventral injection is the lesser occipital nerve, and a C3 injection is the third occipital nerve.
 
As with any procedure, complete documentation helps determine accurate coding and appropriate reimbursement. "Understanding the anatomy of the procedure is a big help when coding for occipital injections," Hammer says. "I urge providers to document specifics related to anatomic structures and needle location. This is for billing com-pliance as well as more importantly medical and legal protection. I believe that specific documentation from the provider helps prevent the 'assumptions' that coders attempt to make in abstracting codes from less-detailed records."

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