Primary Care Coding Alert

4 tools improve your nerve block pay

With conflicting information about whether 64450 (Injection, anesthetic agent; other peripheral nerve or branch) is separately reportable, you're going to need some added ammunition to get paid for a penile nerve block with a circumcision.

You should boost your reimbursement rate using these two arguments and the payer-preferred surgical modifier:

1. Point Out That NCCI's Bundle Is Not Universal

Don't stop billing 64450 for fear of unbundling violations. The National Correct Coding Initiative (NCCI) version 8.3 bundles 64450 into 54150 (Circumcision, using clamp or other device; newborn), says Joanne Sherrill-Drummer, emergency associate coder at Community Hospital of Monterey in Monterey, Calif.

Here's the bottom line: You should still bill private payers and Medicaid for 64450, Sherrill-Drummer says.

2. Explain That the Surgical Package Excludes Nerve Blocks

You should challenge payers for 64450 coverage by giving representatives an anesthesia lesson. Explain that CPT's surgical package bundles digital blocks, not nerve blocks, says Linda Weiss, CPC, coding specialist at Seattle Primary Physicians, which serves 23 family physicians at seven clinics in Seattle.

Here's how: Send the insurer a copy of CPT's surgical package definition that includes "local infiltration, metacarpal/metatarsal/digital block or topical anesthesia." Point out that "a penile nerve block is not considered a local infiltration or topical anesthesia," according to CPT Assistant August 2003. A nerve block is instead a regional anesthesia, which the surgical package doesn't include.

"Make sure you include your FP's documentation, which indicates he gave the penile nerve block for pain management," says Donna Volden, LPN, CPC, clinic coding manager for Affinity Health System, which includes 17 clinics throughout Northeast Wisconsin.

Inform the payer that you are separately reporting 64450 according to correct coding guidelines. "The nerve block is not an integral component of the circumcision procedure," Weiss says.

Tip: Before billing for penile nerve blocks in addition to circumcisions, you may want to alert your top medical insurance directors. "We sent insurers a copy of an AMA letter stating that you may appropriately bill 64450 in addition to 54150, and a physician's explanation of the penile nerve block," Volden says. 

Result: Some of Affinity Medical Group Clinic's insurers are reimbursing for 64450, Volden says.

3. Try Modifier -47

If insurers deny the nerve block, you may need to append modifier -47 (Anesthesia by surgeon) to 54150 in addition to reporting 64450. Indiana Medicaid has been denying penile nerve blocks, says Connie Fullerton, billing manager at Richmond Family Care Center with five FPs in Richmond, Ind. "We are going to try modifier -47 and see if that will get 64450 paid."

Reason: "Use of the modifier '-47' alerts the third-party payer that the surgeon personally performed the anesthesia," CPT Assistant states.

Problem: Even though CPT coding guidelines support appending modifier -47 to 54150, private payers may require that you report penile nerve block differently.

4. Research Payer-Specific Reporting Policies

You should check with your major insurers for their coding requirements for nerve block with circumcision. Some insurers may want you to use modifier -51 (Multiple procedures) on the nerve block code.

Why: Modifier -51 tells the payer that the FP performed the nerve block in addition to a circumcision, Sherrill-Drummer says.