Podiatry Coding & Billing Alert

Hint: You can only report both 64455 and 64632 one time per session.

Morton's neuroma is the most common type of neuroma that podiatrists treat, but do you know when you should report 64455 versus 64632? Read on to make sure you choose the appropriate code for the level of treatment the podiatrist has documented.

Brush Up on Morton's Neuroma Basics

When your podiatrist performs a plantar digital nerve procedure, he is treating a neuroma - an inflamed, painful, enlarged nerve caused by a thickening of nerve tissue. Neuromas are most often found in the common metatarsal nerves of the foot, which are the nerves just behind the toes.

There are many types of neuromas depending upon the area of the foot being discussed, according to Jordan Meyers, DPM, partner at Raleigh Foot and Ankle Center and consultant at Treace Medical Concepts, Inc. in Raleigh, North Carolina.  

From medial to lateral they are: Joplin's, Houser's, Heuter's, Morton's, and Islen's.

Morton's neuroma, the most common type of neuroma, is a sustained irritation or inflammation that causes perineural fibrosis and thickening of the communicating branch between the medial and lateral plantar nerves in the third interspace between the third and fourth metatarsals, Meyers says.

Causes: Playing sports or wearing shoes with a narrow toe box can cause Morton's neuroma.

Symptoms: Symptoms of Morton's neuroma include numbness, burning, and tingling radiating into the toes towards the middle part of the foot.

Morton's neuroma can also feel like a "lump" in the foot or a "balled up sock" around the toes, according to Meyers.

Look to These ICD-10 Options for Morton's Neuroma

Your ICD-10 code choices for Morton's neuroma include the following:

• G57.6-, Lesion of plantar nerve, which includes Morton's metatarsalgia

            o G57.60, Lesion of plantar nerve, unspecified lower limb
            o G57.61, Lesion of plantar nerve, right lower limb
            o G57.62,  Lesion of plantar nerve, left lower limb
            o G57.63, Lesion of plantar nerve, bilateral lower limbs.

Podiatrists can use physical exam, x-rays, and diagnostic ultrasound to diagnose a Morton's neuroma.

Initial treatment includes the following:

• Padding or orthotic devices may provide support and reduce pressure and compression on the nerve
• Activity modification may reduce repetitive pressure on the nerve
• Wearing shoes with a wide box toe can reduce compression of the metatarsal heads and reduce pressure on the nerve
• Medications like NSAIDs to help reduce inflammation.

Depend on These CPT^® Codes for Morton's Neuroma

Second level of treatment: When your podiatrist treats a neuroma through injections, you should report 64455 (Injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s] [eg, Morton's neuroma]).

Code 64455 provides temporary relief of Morton's neuroma. The podiatrist gives this injection in the plantar common digital nerve from the dorsal direction. The podiatrist injects a corticosteroid with an anesthetic around the nerve, which relieves the pressure on the nerve.

Caution: "If you are injecting the neuroma with anesthetic and cortisone, you must make sure you use injection of digital nerve," says Arnold Beresh, DPM, CPC, CSFAC in Newport News, Virginia. "You also are able to bill the injection as well as the proper J code for the cortisone."

Be sure to bill the proper units for the cortisone, Beresh adds. There is still debate about what code to use for injecting the neuroma with a sclerosing solution - especially if using less than a 40 percent solution.

Note: Only report 64455 one time per session, regardless of the number of injections your podiatrist administers. The only exception to this rule 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).

Third level of treatment: The podiatrist may use neurolytic agent or may decide on an advanced procedure such as Cryo Neuro Ablation (64640, Destruction by neurolytic agent; other peripheral nerve or branch) or open surgery. For that he may administer an injection to destroy the nerve root that produces the chronic pain. Report 64632 (Destruction by neurolytic agent; plantar common digital nerve) if the podiatrist uses this procedure through chemical, thermal, electrical, or radiofrequency techniques.

Your podiatrist may also use an alcohol technique, which involves injecting an alcohol solution near a target nerve tissue to eliminate or diminish the ability of the nerve to transmit pain signals. Percutaneous Alcohol (30-100 percent solution) is used to destroy theneuromas.

If the podiatrist finds a clinically positive response and the symptoms are significantly reduced after two injections, up to maximum three additional (or less if the patient reports elimination of neuroma symptoms) injections are allowed at 14-day intervals. You can report 64632 for each injection. Commonly, in such cases, podiatrists have to use fluoroscopic guidance to deliver the injections accurately.

Note: You can only report 64632 one time per session, regardless of the number of injections your physician administers. 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).

When reporting 64455 or 64632, often times insurance companies will only pay for one injection on the given day, no matter how many sites are involved, even if the podiatrist injects different feet, according to Beresh.