Peripheral nerves cause pain in various conditions, such as post-herniorrhaphy pain, iliac crest harvest syndromes, carpal tunnel syndrome, Morton’s neuroma, facial pain and headaches. Peripheral nerve blocks (PNBs) are a safe alternative to opioids for acute pain management and help anesthesiologists to provide safe and effective patient care. PNBs for the treatment of chronic pain post-herniorrhaphy can help avoid more aggressive treatments (e.g., surgery). With the advancement of techniques, billing and coding for nerve blocks can be challenging. Partnering with a pain management medical billing and coding company that understands this area and is familiar with the latest CPT codes and their relative value is critical to decrease claim denials and maximize reimbursement.
PNBs – Uses and Indications
PNBs can be used for both diagnostic and therapeutic purposes.
- When used diagnostically, a PNB allows the clinician to insulate the specific cause of pain in an individual patient.
- Indications for therapeutic PNBs include:
- To provide prompt and effective analgesia, either as a local anaesthetic prior to suturing or following injury (such as femoral nerve block for a broken leg)
- To facilitate proper examination, intervention or mobilization of an injured area without the need for sedation or general analgesia
Nerve blocks are injected near the nerves using ultrasound. There are three types of PNBs:
- Lower extremity nerve blocks
- Nerve blocks of the abdomen and thorax
- Upper extremity nerve blocks
PNBs for acute pain can be administered in two ways: as a single shot injection and via continuous catheters. For chronic pain, PNBs can be used only as part of an active component of a comprehensive pain management program.
It is the clinician’s responsibility to determine the medical necessity and proper site of service for the procedure, and to submit appropriate codes, charges and modifiers for services rendered. Knowing payer rules is important to submit accurate claims for optimal reimbursement. For instance, Aetna considers the following PNBs medically necessary:
- Peripheral nerve blocks (continuous or single-injection) for the treatment of acute pain, and for chronic pain only as part of an active component of a comprehensive pain management program.
- Peripheral nerve blocks for the treatment of chronic pain post-herniorrhaphy to avoid more aggressive treatments (e.g., surgery).
Aetna considers the following PNBs experimental and investigational (not an all-inclusive list) because their effectiveness for these indications has not been established:
- Peripheral nerve blocks as sole treatment for chronic pain.
- Peripheral nerve blocks (e.g., greater occipital (GON), supratrochlear (STN), and supraorbital (SON) nerve blocks) for the prevention or treatment of headaches including (migraine headaches and treatment-refractory migraine in pregnancy), and for the treatment of short-lasting unilateral neuralgiform headaches.
- Repetitive peripheral nerve blocks for chronic non-malignant pain.
Peripheral Nerve Block 64405 CPT Code Description and Related Codes
The CPT code set for nerve blocks is 64400-64530 Peripheral nerve blocks-bolus injection or continuous infusion:
- 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch
- 64402 Injection, anesthetic agent; facial nerve
- 64405 Injection, anesthetic agent; greater occipital nerve
- 64413 Injection, anesthetic agent; cervical plexus
- 64415 Injection, anesthetic agent; brachial plexus, single
- 64416 Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement)
- 64417 Injection, anesthetic agent; axillary nerve
- 64418 Injection, anesthetic agent; suprascapular nerve
- 64420 Injection, anesthetic agent; intercostal nerve, single
- 64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block
- 64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves
- 64430 Injection, anesthetic agent; pudendal nerve
- 64445 Injection, anesthetic agent; sciatic nerve, single
- 64446 Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement)
- 64447 Injection, anesthetic agent; femoral nerve, single
- 64448 Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement)
- 64449 Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement)
- 64450 Injection, anesthetic agent; other peripheral nerve or branch
- 64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton’s neuroma)
According to Medicare First Coast Service Options, Inc., based on Medicare rules, regulations, and Correct Coding Initiative (CCI) edits, CPT codes 64400-64530 may be reported on the date of surgery, if performed for post-operative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve block codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique.
CPT Code Modifiers
Modifier-59 is used to indicate a distinct procedure. When happended to the CPT code for PNB, modifier 59 identifies the PNB as a postoperative pain procedure. This modifier can be used whether the nerve block was performed preoperatively or postoperatively. Including the modifier is important to indicate that the PNB is not part of the intraoperative anesthetic technique. The details of a PNB procedure performed for postoperative pain management should not be included in the intraoperative anesthetic record. For bilateral procedures, code modifier-50 should be added to the primary code.
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ICD-10 codes that Support Medical Necessity
Medicare First Coast Service Options, Inc. lists the ICD codes that may support medical necessity of peripheral nerve blocks. The list below is not all inclusive.
For CPT codes 64400-64449:
- B02.22 Postherpetic trigeminal neuralgia
- B02.23 Postherpetic polyneuropathy
- B02.9 Zoster without complications
- C00.0 – C86.6 Malignant neoplasm of external upper lip – Primary cutaneous
- CD30-positive T-cell proliferations
- C88.2 – C96.4 Heavy chain disease – Sarcoma of dendritic cells (accessory cells)
- C96.A Histiocytic sarcoma
For CPT code 64450:
- B02.22 Postherpetic trigeminal neuralgia
- B02.23 Postherpetic polyneuropathy
- B02.9 Zoster without complications
- C00.0 – C86.6 Malignant neoplasm of external upper lip – Primary cutaneous
- CD30-positive T-cell proliferations
- C88.2 – C96.4 Heavy chain disease – Sarcoma of dendritic cells (accessory cells)
- C96.A Histiocytic sarcoma
- C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue
- C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified
For CPT code 64455:
- G57.60 – Lesion of plantar nerve, unspecified lower limb – Lesion of plantar nerve, bilateral lower limbs
- G57.63 – (ICD-10 codes G57.60 – G57.63 should be used for Morton’s metatarsalgia, neuralgia, or neuroma)
In the ever-evolving billing and coding scenario, billing and coding for peripheral nerve blocks can be complex. Providers can keep up with coding changes and new billing practices to ensure compliance and maximum payment for services by consulting an experienced pain management medical billing company.
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