Podiatry Coding & Billing Alert

Look for strength of alcohol injection to code 64455 or 64632.

When your podiatrist performs digital nerve procedures, you have so many variables to deal with -- the number of nerves, use of fluoroscopy, and accompanying tendon repair-- to report these procedures successfully. We give you four simple steps to help you arrive at the picture perfect claim. 

#1. Know Your Neuroma

When your podiatrist goes for plantar digital nerve procedure, it means he is planning to treat a neuroma. A neuroma is an inflamed, painful, enlarged nerve caused by a thickening of nerve tissue that may develop in various parts of the body. Neuromas are most often found in the common metatarsal nerves of the foot which are the nerves just behind the toes. The most common neuroma in the foot is a Morton’s neuroma, also as an intermetatarsal neuroma, which occurs between the third and fourth toes. Neuromas may also occur in other locations in the foot. Symptoms usually include pain, tingling, burning, or numbness.

The last resort for treating the neuroma is surgery. However, before opting for surgery, your podiatrist will try to treat the condition with injections or destruction of the pain-causing nerve.

#2. Go for 64455 for Pain Relief Injections

The first line of defense against plantar nerve inflammation is a steroid or anesthetic agent for pain relief. When your podiatrist treats the neuroma through injections, you should report 64455 (Injection[s], anesthetic agent and/or steroid, plantar common digital nerve[s] [e.g., Morton’s neuroma]). This injection is given into the plantar common digital nerve from the dorsal direction. The physician injects a corticosteroid (such as triamcinolone, depomedrol, or prednisone) with an anesthetic (e.g., lidocaine) around the nerve, because they can shrink the swelling of the nerve. This relieves the pressure on the nerve. Although up to three cortisone injections were allowed over a twelve-month period earlier, now more than three can be given. 

#3. Take the Next Step With 64632

If there is no relief after using pain relievers, the podiatrist takes the treatment to the next level. “The podiatrist may decide to use a 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,” informs Arnold Beresh, DPM, CPC, Peninsula Foot and Ankle Specialists PLC in Hampton, Va. 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 physician uses this procedure through chemical, thermal, electrical, or radiofrequency techniques.

Your podiatrist may use an alcohol technique, which involves injecting an alcohol solution near a target nerve tissue in order to eliminate or diminish the ability of the nerve to transmit pain signals. Percutaneous Alcohol (30-100 percent solution) is used to destroy the neuromas. 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, physicians have to use fluoroscopic guidance to deliver the injections accurately.

If your podiatrist uses fluoroscopic/ultrasound guidance for either the nerve block or destruction, then you can report that separately. “Most podiatrists will use ultrasound guidance not fluoroscopic guidance,” says Dr. Beresh. Add code 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]) to your claim. Append modifier 26 (Professional component) if the procedure is performed in a facility. 

Watch this: Alcohol injections can also be used as nerve sclerosing (pain reducing) agents. If the physician has documented alcohol (4-29 percent solution) as a sclerosing agent to relieve pain, you will report 64455 and not 64632. Two injections (administered at 5-10 day intervals) is the usual protocol. Report 64455 for each injection. Look for the strength of the solution to decide the code.

Another popular office procedure for neuroma destruction is called Radiofrequency Ablation for Neuromas, during which the physician inserts a radiofrequency probe into the foot right at the inflamed nerve and heats up the tip of the probe. The pinpoint spot of heat denatures the proteins of the nerve and stops the pain transmission through it. “Since this is thermal ablation, you can use 64640 for this procedure,” suggests Dr. Beresh.

#4. Don’t Stumble on These Nerve Procedure Obstacles

You stand a better chance of filling accurate neuroma treatment claims if you heed these three advice points:

• You only report 64455 once per session, regardless of the number of injections your physician administers; the same holds true for 64632. However, if your podiatrist provides the treatment to both feet in the same session, you can report the appropriate code twice in those cases and append modifiers LT (Left side) and RT (Right side). “At this time, Medicare is only paying for one injection no matter how you document it,” informs Dr. Beresh.
• CPT® code 64455 is bundled with 64632 with a “0” modifier and cannot be reported together in any circumstance. Both codes have zero global days.
• In case of ultrasound aid, report 77003 only once per region, regardless of how many injections your physician administers. As per guidelines for 77003, 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.

Medical necessity: Medicare will pay for injections of sclerosing (neurolytic), anesthetic or steroid agents for treatment of Morton’s neuroma only when all the following conservative therapies have failed:

• Padding or orthotic devices (these can provide support to reduce pressure and compression on the nerve)
• Activity modification (to reduce repetitive pressure on the nerve)
• Changes in shoe wear (shoes with a wide box toe are advised to reduce compression of the metatarsal heads and reduce pressure on the nerve)
• Medications unless otherwise contraindicated (for example, nonsteroidal anti-inflammatory drugs [NSAIDs] which help reduce inflammation).