Podiatry Coding & Billing Alert

You should report 64455, 64632 once — except in this situation.

Choosing the correct CPT^® code for plantar digital nerve injection and destruction procedures depends on your physician’s treatment plan. Read on how to perfect these claims.

Background: You should use M72.2 (Plantar fascial fibromatosis) to describe heel pain caused by inflammation of the plantar fascia or the fibrosis of the plantar fascia. There could be a variety of sources of this condition, including participating in athletics without appropriate warm-up, stress on the arch, ill-fitting shoes, and sports-related stress on the heel. Toe, foot and ankle problems can be caused by wear-and-tear, or by sudden injuries, such as those from jumping during sports. If your podiatrist attends to plantar digital nerve problems, read on to find what your coding options are.

1. Get the History of Your CPT^® Options

The codes you might need to use represent very different services — nerve destruction versus nerve injection — but you could find yourself repeatedly relying on both:

• 64455 — Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton’s neuroma)
• 64632 — Destruction by neurolytic agent; plantar common digital nerve.

History: Your choices in these situations before 2009 were 64450 (Injection, anesthetic agent; other peripheral nerve or branch) and 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). The codes introduced in CPT^® 2009 pay less than 64450 or 64640, but are important because their specificity helps increase your coding accuracy.

2. Know When to Call on 64455 or 64632

You’ll use both 64455 and 64632 when your podiatrist treats a condition affecting plantar common digital nerves.

One of the most common scenarios would be when a patient presents with Morton’s neuroma — a thickening of the plantar nerve between the heads of the metatarsals (G57.60, Lesion of plantar nerve, unspecified lower limb; or G57.61, Lesion of plantar nerve, right lower limb; or G57.62, Lesion of plantar nerve, left lower limb). Symptoms usually include pain, tingling, burning, or numbness. Playing sports or wearing shoes with a narrow toe box can cause it.

Basically, 64455 is a steroid injection for temporary relief of Morton’s neuroma. Code 64632 represents a more invasive treatment option for chronic pain. The nerve root that produces the chronic pain is destroyed by chemical, thermal, electrical, or radiofrequency techniques while leaving sensation intact.

Pay attention to your podiatrist’s treatment plan. If he injects a steroid or anesthetic agent for pain relief, report 64455. If he takes treatment to the next level, however, and administers an injection to destroy the nerve (sometimes called chemodenervation), you’ll submit 64632 instead.

Counting exception: You only report 64455 one time per session, regardless of the number of injections your physician administers; the same holds true for 64632. The exception is when your podiatrist provides bilateral treatment. You’ll report the appropriate code twice in those cases and append modifiers LT (Left side) and RT (Right side).

3. Steer Clear of Injection Edits

The National Correct Coding Initiative (CCI) edits include 64455 and 64632 in bundled pairs. Watch what services you might want to code in conjunction with 64455 or 64632 because they both include the work represented by:

• microsurgery code +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure])
• muscle and nerve test codes 95860-95861, 95867-95868, 95870, 95900, 95904, 95920, 95925-95930, 95933-95934, 95936-95937.

Because these edits carry a modifier indicator of “0,” you cannot unbundle them and separately report the procedures for any reason.

4. Remember Ultrasound Guidance

If your podiatrist uses ultrasonic guidance for either the nerve block or destruction, then add 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) to your claim. Code 76942 reports only the supervision and interpretation done by the physician during the ultrasonic guided needle placement. Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.

Append modifier 26 (Professional component) if the procedure is performed in a facility site of service, meaning place of service code 21 (Inpatient hospital), 22 (Outpatient hospital), or 24 (Ambulatory surgical center).

“When performed in the office, you only need to bill the procedure code,” Arnold Beresh, DPM, CPC, CSFAC, of Peninsula Foot and Ankle Specialists PLC in Hampton, Va. reminds us.

Reminder: Do not report 76942 in conjunction with 10030, 19083, 19285, 20604, 20606, 20611, 27096, 32554, 32555, 32556, 32557, 37760, 37761, 43232, 43237, 43242, 45341, 45342, 64479-64484, 64490-64495, 76975, 0213T-0218T, 0228T-0231T, 0232T, 0249T, 0301T.

Coding tip: Given the specificity that ICD-10 demands, remember that you need modifiers to help differentiate work on different areas of the feet or toes. These modifiers include LT (Left side) and RT (Right side), TA-T9 (for the individual toes), and sometimes 59 (Distinct procedural service), depending on the service your podiatrist provides. These modifiers become particularly important if the physician performs the same procedure on more than one foot or toe.

Watch for: To report 76942 compliantly, your physician should include documentation stating that he used ultrasound guidance for the procedure. According to American College of Radiology guidelines, the documentation should include details about the procedure and materials, findings, and your physician’s impressions.