Anesthesia Coding Alert

Correct 64400 and 64405 coding helps ensure payment.

If your practice is looking to add bilateral occipital or trigeminal nerve blocks as a headache-relief service to your patients, there are a few tips you can use to ensure proper coding and reimbursement. Take a look at what doctors and coders are doing to bring relief to patients and payment to the practice.

Step 1: Know the Blocks’ Purpose and Location

For bilateral occipital or trigeminal nerve blocks, you’ll be using codes 64405 (Injection, anesthetic agent; greater occipital nerve) or 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch).

Occipital: The greater occipital nerve originates from the C2 spinal nerve and provides sensory innervation to the posterior area of the scalp extending to the top of the head. Physicians typically inject the greater occipital nerve (GON) just above the base of the skull for occipital or cervicogenic headaches or neck pain.

64405: "We usually report the code for occipital nerve block in patients with a condition known as occipital neuralgia," says Wayne Sida, MD, in Greenwood, S.C. This painful condition produces an aching, burning, or throbbing type of pain, tingling -- and, sometimes, numbness on the back of the head in the distribution of the greater occipital nerve.

A nerve block can be either diagnostic, therapeutic, or both, Sida says. Physicians also have used occipital nerve blocks to treat certain types of headache, including cluster headaches.

Trigeminal: The trigeminal nerve, also known as cranial nerve V or the fifth cranial nerve, provides sensory innervation to most of the face. The term "trigeminal" is derived from the fact that the cranial nerve has three major divisions or branches:

• The ophthalmic nerve, or V1 division, primarily provides sensory innervation to the forehead and eye area.

• The maxillary nerve, or V2 division, provides sensory innervation to the upper jaw area from below the eye to the upper lip.

• The mandibular nerve, or V3 division, provides both sensory and motor innervation to the lower jaw area of the face.

Trigeminal injections can be performed at any of the three divisions or branches of the divisions and can be used for cluster, tension, or migraine headaches, or atypical facial pain, says Debbie Farmer, CPC ACS-AN, with Auditing for Compliance and Education Inc. in Leawood, Kan.

64400: Providers may use different terms than "trigeminal" when noting the branch being injected, which could confuse coders, Farmer says. She recommends coders use an anatomy book to help. Use 64400 for injections to any of the three divisions or more distal branches, including the supraorbital, the infraorbital, and the auriculotemporal nerve.

The trigeminal nerve block is used much less frequently, Sida says. "I have used this code for patients who had herpes zoster (shingles) on the face and developed post-herpetic neuralgia," he adds.

Trigeminal neuralgia (also known as tic douloureux) might also be a diagnosis for this code.

Watch for nerve destruction: Occasionally, the treatment of tic douloureux involves the permanent destruction of the nerve by injection of a neurolytic agent, such as 100 percent alcohol, rather than injection of local anesthesia. In this case, make sure to use the codes for destruction of nerves (64600-64681, "Destruction by Neurolytic Agent [e.g., Chemical, Thermal, Electrical or Radiofrequency]").

Step 2: Review Your Carrier Rules

Some insurance companies consider 64405 "experimental or investigational" and may deny it, Farmer says. Review coverage determinations from individual carriers prior to the injection for appropriate medical necessity-supporting diagnosis codes, as well as limitation and bundling edits. Preauthorization is always important, but knowing the carrier’s policies and limitations will help prevent denials and get your physician paid for the services provided.

Keep up with CMS: "Modifier 59 (Distinct procedural service) should not be necessary when using the codes together according to the Correct Coding Initiative, but not all carriers follow these guidelines," Farmer notes.

Restriction lifted: With the second quarter Medicare Physician Fee Schedule update in April 2008, CMS lifted the restriction for reporting these injections bilaterally. Effective for dates of service back to Jan. 1, 2008, modifier 50 (Bilateral procedure) is an acceptable option to add to 64400 and 64405. Most Medicare contractors request that providers report bilateral services as one line item with the 50 modifier appended and one unit of service, such as 64405-50 x 1.

Remember, if the procedure is bilateral, Medicare will process the service at 150 percent of the allowed amount. That means you should get reimbursed 100 percent for the first injection and another 50 percent for the second contralateral one.

Heads up: For Medicare, providers should use modifier 50 for either of the two injection codes, not RT (Right side) and LT (Left side). Some non-Medicare payers require providers to report bilateral services as two line items -- one with the RT modifier and one unit of service and the second line item with the LT modifier and one unit of service.

Step 3: Study the Dx Code

Choosing the correct diagnosis code is a key to the accuracy and success of your claims.

Example 1: If your pain management specialist notes "occipital neuralgia," in her documentation, don’t miss that the ICD-9 alphabetic index directs you to the musculoskeletal system chapter, not the nervous system chapter. You should report 723.8 (Other syndromes affecting cervical region). Occipital neuralgia is a persistent neuropathic-type pain caused by an injury or irritation to the occipital nerve.

Example 2: If your pain management specialist indicates "occipital headache" as the diagnosis, be aware there is no specific listing for occipital under "headache" in the ICD-9 alphabetic index. Use the diagnosis code 784.0 (Headache) from the "Symptoms, Signs and Ill-defined Conditions" chapter.

Checklist: Headache Dx Codes

There are several headache codes you might encounter when coding for occipital or trigeminal nerve blocks. Clip and save this checklist if your practice regularly administers these blocks:

• 053.12 -- Postherpetic trigeminal neuralgia

• 307.81 -- Tension headache

• 339.0X -- Cluster headaches

• 339.1X -- Tension type headache

• 346.XX -- Migraine

• 350.1 -- Trigeminal neuralgia.