Podiatry Coding & Billing Alert

CPT 2009 introduced two new codes for plantar common digital nerve procedures, giving you better choices than the "other nerve" options you previously resorted to. Now that you have more specific codes in your arsenal, however, be sure you know their ins and outs for success.

The new codes 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.

Your previous choices in these situations were 64450 (Injection, anesthetic agent; other peripheral nerve or branch) and 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). The new codes 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 (355.6, Lesion of plantar nerve). Symptoms usually include pain, tingling, burning, or numbness. Playing sports or wearing shoes with a narrow toe box can cause it.

"Basically, 64455 is just your steroid injection for temporary relief of Morton's neuroma," explains Tara Homan, senior biller with Alpha Medical Billing Associates in Lima, Ohio. "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." Choosing the correct code depends on your physician'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: According to CPT Changes 2009: An Insider's View, 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), says Kristina Newton, CPC, billing coordinator for Sarasota Orthopedic Associates in Sarasota, Fla.

CCI edits were quick to include 64455 and 64632 in bundled pairs earlier this year. 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.

If your podiatrist uses fluoroscopic guidance for either the nerve block or destruction, then add 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) to your claim. 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).

Report 77003 only once per region, regardless of how many injections your physician administers.

Watch for: To report 77003 compliantly, your physician should include documentation stating that he used fluoroscopic 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.