General Considerations
The popliteal block is a block of the sciatic nerve at the level of the popliteal fossa. This block is one of the most useful blocks in our practice. Common indications include corrective foot surgery, foot debridement, and Achilles tendon repair. A sound knowledge of the principles of nerve stimulation and the anatomic characteristics of the connective tissue sheaths of the sciatic nerve in the popliteal fossa are essential for its successful implementation.
Functional Anatomy
The sciatic nerve is a nerve bundle consisting of two separate nerve trunks,
the tibial and the common peroneal nerves (Figure 1-2). A common epineural sheath envelops these two nerves at their outset in pelvis. As the sciatic nerve descends toward the knee, the
two components eventually diverge in the popliteal fossa to continue their paths separately as the tibial and the common peroneal nerves. This division of the sciatic nerve usually occurs between 4 and 10 cm proximal to the popliteal fossa crease. From its divergence from the sciatic nerve, the common peroneal nerve continues its path downward and laterally, descending along the head and neck of the fibula, Figure 1-2. Its major branches in this region are branches to the knee joint and cutaneous branches to the sural nerve. Its terminal branches are the superficial and deep peroneal nerves. The tibial nerve is the larger of the two divisions of the sciatic nerve. It continues its path vertically through the popliteal fossa, and its terminal branches are the medial and lateral plantar nerves, Figure 1-2. Its collateral branches give rise to the medial cutaneous sural nerve, muscular branches to the muscles of the calf, and articular branches to the ankle joint. It is important to note that the sciatic nerve in the popliteal fossa is lateral and superficial to the popliteal artery and vein, and it is contained in its own tissue (epineural) sheath rather than in a common neurovascular tissue sheath. This anatomic characteristic explains the relatively low risk of systemic toxicity and vascular punctures with a popliteal block (Figure 1-3). However, the proximity of the large vessels, popliteal artery, and vein still makes it imperative to carefully rule out an intravascular needle placement by careful aspiration and meticulously slow injection (e.g., ≤20 mL/min).
http://www.nysora.com/techniques/ne...er-extremitya/3264-transgluteal-approach.html
As seen above, the sciatic nerve branches to two other peripheral nerves:
"two components eventually diverge in the popliteal fossa to continue their paths separately as the tibial and the common peroneal nerves."
"This division of the sciatic nerve usually occurs between 4 and 10 cm proximal to the popliteal fossa crease."
I would review the fact that insertion site of the needle, is it confirmed that this is still the sciatic nerve or it is actually an other peripheral branch at this point.
When reviewing the code descriptor for CPT 64445 it is noted that it does not mention the branch of the femoral nerve. A recent AMA CPT Assistant article gives an example of using 64450 for a fascia iliac block. Does the manager agree that a fascia iliac block is 64450 not 64447. Then using the similar concept if the sciatic nerve itself is not being blocked at the popliteal level then it would seem CPT 64450 would represent the actual nerve that is being injected.
64445 Injection, anesthetic agent; sciatic nerve, single
As seen below, the AMA is identify which nerve is being blocked if the nerve is being blocked falls under an "other peripheral nerve or branch" than CPT 64450 would most accurately describe the nerve being targeted.
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AMA CPT Assistant
September 2015 page 12
Frequently Asked Questions:Surgery: Nervous System
Question: There seems to be a lot of confusion as to whether fascia iliaca block is reported with CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch; code 64447, Injection, anesthetic agent; femoral nerve, single; or code 64448, Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement). Which code is appropriate?
Answer:A fascia iliaca block may be reported with code 64450. This code is utilized for the diagnostic or therapeutic introduction or injection of an anesthetic agent in a peripheral nerve or branch. It is not appropriate to report code 64450, if the injection serves to provide anesthesia for a surgical procedure