pain management branch nerve blocks

Still confused with Coding and reporting medial and lateral branch nerve blocks and understanding Pain Management procedures?

Coding Billing for Medial and Lateral Nerve Blocks.

According to the AMA, the code series for medial branch blocks and the facet joint injections are the same (i.e., CPT series 64490-64495), with reporting based on the number of facet joints injected, not the number of nerves injected. 

For example: If three (3) medial branch nerves are injected only two (2) facet joint injection codes would be reported despite the fact that three nerves were injected, since each facet joint is connected to two medial nerves.

The lateral branch nerve is a peripheral nerve and would be reported with CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, when a lateral branch nerve block is performed.

Please note: CPT code 64450 should only be reported per nerve or branch and not per injection.

CPT code 76942, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation, would be additionally reported when utilizing ultrasound guidance for certain nerve block procedures when it is not inherent in the primary procedure code.

The Different kinds or types of NERVE BLOCKS and what are they targeting:
   
NERVE BLOCKS: Brachial plexus block, elbow block, wrist block BODY AREAS: Shoulder, arm, hand, elbow, wrist)
NERVE BLOCKS: Cervical epidural, thoracic epidural, lumbar epidural block BODY AREAS: Neck, back
NERVE BLOCKS: Cervical plexus block, cervical paravertebral block BODY AREAS: Shoulder, upper neck   
NERVE BLOCKS: Maxillary nerve block BODY AREAS: Upper jaw  
NERVE BLOCKS: Ophthalmic nerve block BODY AREAS: Eyelids, scalp   
NERVE BLOCKS: Sphenopalatine nerve block BODY AREAS: Nose, palate   
NERVE BLOCKS: Subarachnoid block, Celiac plexus block BODY AREAS: Abdomen, pelvis   
NERVE BLOCKS: Supraorbital nerve block BODY AREAS: Forehead   
NERVE BLOCKS: Trigeminal nerve block BODY AREAS: Face

CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA

CPT CODE 64490 PARAVERTEBRAL FACET JOINT BILLING AND CODING WITH IMAGING GUIDANCEInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64491 ----------- second level
64492 ----------- third and any additional level(s) level
CPT CODE 64493Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
64494 ----------- second level
64495 ----------- third and any additional level(s) level
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FACET JOINT BILLING AND CODING WITH ULTRA-SOUND
0213T
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
....................................................................+ 0214T second level
....................................................................+ 0215T third and any additional level(s)
0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
..................................................................+ 0217T second level
..................................................................+ 0218T third and any additional level(s)
Billing and Coding for Radiofrequency Facet denervationCPT

CODE 64633
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint'

+64634 cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

CPT CODE 64635
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint;

+64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
​
Other Searched Keywords:
Billing and Coding for RFA of Facet Joint Nerves
Billing and Coding for Facet Joint AblationKey Points for CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA

These codes are unilateral

• Append Modifier 50 when its bilateral
• CPT 64490, 64493, 64495, 64633 are performed with Imaging Guidance; it's inappropriate to report these codes if its not with imaging guidance
• If its under ultra-sound, use the Category 3 Codes shown above
• You don't need Modifier 51 for the add-on codes +64491, +64496, +64634, +64636
• Place of Service applicable to POS 11, 24, 22

Let's look at these questions and answers:
#1 Question
"What are the appropriate code assignments when a patient receives 3 separate nerve blocks into the same lateral branch nerve? Would it be appropriate to report 3 units of this service?"
The right CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, would be appropriately reported only once in this case since all 3 nerve blocks were administered to the same nerve or branch.

#2 Question
"We are getting conflicting information regarding coding medial and lateral branch blocks S1, S2, and S3, Medial 64493, 64494, Lateral 64493, and 64494. Our Pain Center wants to use facet injection for the medial branch block and other peripheral nerve for the lateral branch block. Are we correct in reporting lateral branch nerve block(s) to the peripheral nerve CPT code?" Yes, you are correct. The lateral branches of the dorsal sacral nerve plexus are considered peripheral nerves. Therefore, for the four lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch. Report multiple units of the injection for the four lateral branch block injections performed, modifier 59 would not be appended in this case.

# 3 Question
"A patient was seen at our facility and underwent a left-sided L5 and S1, S2, S3, and S4 lateral branch nerve block for diagnostic purpose with C-arm fluoroscopy. What are the correct codes for a lateral nerve block?"

So OK, ... based on the operative report a medial branch nerve block was performed at the L5 and a lateral branch nerve block was performed at the S1, S2, S3 and S4

Therefore, it would be appropriate to report CPT code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapohphyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level, for the L5 medial branch block.

For the 4 lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch.

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Insurance Prior Authorization Services, Patients Access and Medical Documentation Reviews and Audits.

From AMA's CPT Assistant:
February 2011 page 4

(In September 2011 questions relating to this article were discussed.)
Revisions made to certain pain medicine procedures in the CPT 2011 codebook include new procedure codes, and guidelines were created in the Nervous System section to clarify the reporting of these services. The following code sets are affected:
• Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic (64400-64530)
• Neurostimulators (Peripheral Nerve) (64550-64595)
• Destruction by Neurolytic Agent (eg, Chemical, Thermal, Electrical or Radiofrequency) (64600-64681)
Introduction/Injection of Anesthetic Agent (Nerve Block), Diagnostic or Therapeutic Revised Codes

The following codes were revised for 2011:
 64479Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
 64480Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
 64483Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
 64484Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)
What exactly is "transforaminal epidural injection"? codes 64479-64484. TFE describe injections that enter the epidural space through the intervetebral foramen.
This technique differs from interlaminar / translaminar epidural injection technique (62321-62327) and the paravertebral facet joint nerve injection technique (64490-64495). Since the vertebral artery (in the cervical spine), radiculomedullary arteries, as well as the spinal cord are in close proximity to the nerve root, this procedure involves a much higher risk with more work than a translaminar epidural injection.

If ultrasound is used to guide the transforaminal injections, a code from the category III code set should be used instead of a code from the 64479-64484 code series. Therefore, parenthetical notes instruct users to report Category III codes 0228T, 0229T, 0230T, and 0231T for ultrasound-guided transforaminal epidural procedures. Additionally ultrasound guidance procedure code 76942, Ultrasound guidance for needle placement (eg biopsy, aspiration, injection, localization device), imaging supervision and interpretation, has been revised to clarify that it may not be used as guidance for 64479-64495 injections.
Coding Tip
Codes 64479-64484 are inherently unilateral procedures. When these procedures are performed bilaterally, they should be appended with modifier 50 or with a HCPCS Level II modifier "RT" or "LT" depending upon payer requirements.
Paravertebral Spinal Nerves and Branches New Guidelines
The paravertebral facet joint is the site of interaction between the vertebral bone above and below, and can be a source of pain. Injections can be made either into the joint, or at each of the nerves that supply the joint (ie, the medial nerve branches).
To coordinate with the revision of codes 64479-64484, new parenthetical notes in the Paravertebral Spinal Nerves and Branches section of the CPT codebook direct users to the appropriate code to identify paravertebral facet joint injections when performed with imaging guidance. When performing a paravertebral facet injection into the T12-L1 joint, or at the nerves innervating that joint, code 64490 is reported.
Fluoroscopy and CT imaging guidance and any injection of contrast are inclusive components of codes 64490- 64495. Imaging guidance and localization are required for the performance of paravertebral facet joint injections, as described by codes 64490-64495. If imaging guidance is not used, code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s), or code  20553 , Injection(s); single or multiple trigger point(s), 3 or more muscle(s), should be reported instead of a code from the 64490-64495 code series. If ultrasound guidance is used, it is appropriate to report Category III codes 0213T-0218T.
Coding Tip
Paravertebral facet injection codes 64490-64495 and 0213T-0218T are unilateral. When performed bilaterally, they may be appended with modifier 50 or a HCPCS Level II modifier "RT" or "LT" depending on the requirements of the payer.
​
Neurostimulators (Peripheral Nerve) New Codes
Code 64573 was deleted and the following four new codes were added for 2011:
 64566Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
 64568Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
 64569Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator
 64570Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator
Code 64566 is reported for a treatment of voiding dysfunction (eg, urge incontinence), posterior tibial nerve stimulation. Code 64566 was created to describe a minimally invasive procedure that includes both the needle insertion through the skin adjacent to the tibial nerve, as well as the placement of an electrode on the surface of the skin. The treatment consists of a series of sessions involving insertions of a percutaneous needle electrode, with intermittent neuromodulation for approximately 30 minutes while the needle electrode remains in place. The neurostimulator includes a lead set with surface electrodes and a needle electrode, which produces an adjustable electrical pulse that travels to the sacral nerve plexus via the tibial nerve. The sacral nerve plexus then regulates the bladder and the pelvic floor functionality. Code 64566 would be reported once for each neurostimulation treatment session.

References:
2017 / 2018 Coding Books (CPT is a Trademark and Owned by the American Medical Association)
AMA's CPT Assistant Archives
CMS Medicare Website (LMN, NCD/LCD, Manuals)
Commercial Payers Guidelines