Neurology & Pain Management Coding Alert

Pay attention to payer’s conservative treatment guidelines.

Patients that require nerve injections are a common sight in a PM practice. During her HEALTHCON 2024 presentation “Taking the Pain Out of Pain Management,” Jessyka Burke, BHSA, CPC, COSC, CASCC, discussed some of the more common nerve injections that PM providers perform.

She ran down five common nerve injection procedures, and how to look for them in the notes.

Check out what she had to say.

Know Conservative Tx Guidelines

For most nerve injections, payers are going to want to see an effort made toward reducing the patient’s pain by more conservative, and less invasive, means. Your provider must document any types of conservative treatment they tried to treat the patient before resorting to injections.

Here is Burke’s the first level of conservative pain management techniques:

• Rest
• Ice
• Reduction of activities of daily living (ADL)
• Therapies: Occupational, physical, massage
• Diagnostic tests: X-rays, magnetic resonance imaging (MRI), computed tomography (CT) scan, electromyography (EMG)
• Chiropractic care
• Complementary and alternative medicine: Acupuncture, cannabidiol (CBD) products, bracing, etc.

Before coming to a PM specialist, “most people have tried these treatments,” Burke said. If they haven’t, payers might require attempts to treat the pain using one of the above methods. Check with your payer if you have any questions about conservative treatment guidelines.

When the patient reports to the PM specialist, Burke said they will likely start with medication: non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and cannabis products, in some cases. If none of these treatments alleviates the patient’s pain, it’s likely time for an injection.

Use 64405 for GON Block

Burke described a trio of nerve injections that your provider might see. The first was a greater occipital nerve (GON) block, which can be used to treat chronic headaches or migraines. During a GON block, the physician injects a local anesthetic around the GON; they might also inject a corticosteroid.

Report GON blocks with 64405 (Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve).

The next injection was a sciatic nerve block. This injection is for treatment of pain in the sciatic nerve, which originates in the lower back and extends down the back of each leg. Report sciatic nerve blocks with 64445 (… sciatic nerve, including imaging guidance, when performed).

Another injection Burke discussed was a genicular nerve block. This injection provides relief from knee pain by blocking the genicular nerves, sensory nerves that transmit pain signals to the brain from the knee joint. Report genicular nerve blocks with 64454 (… genicular nerve branches, including imaging guidance, when performed).

Check Out This Clinical Example

Here’s a detailed clinical scenario from Burke. Read through it, and see if you can choose the proper nerve injection code.

Px suffers from Chronic inflammatory demyelinating polyneuritis. After verbal consent was obtained and using Labat’s technique, I performed a right sciatic nerve block injections procedure using 1cc of 1% lidocaine combined with sodium bicarbonate with a 30 gauge 1” needle for numbing under sterile technique. Once the lidocaine numbed the tissue, I used a 25-guage 3 ½” spinal needle which was advanced toward and into the piriformis muscle at the point of the sciatic nerve impingement, injecting an additional 2 cc of 1% lidocaine and sodium bicarbonate under sterile technique. They tolerated the procedure well and there were no adverse side effects.

This is a sciatic nerve block. On the claim, report 64445 with G61.81 (Chronic inflammatory demyelinating polyneuritis) appended to represent the patient’s polyneuritis.

Use These Codes for Botox^® Shots

Another common type of injections at PM clinics are onabotulinumtoxinA (Botox^®) shots. These shots are often used to treat conditions such as chronic migraine and cervical dystonia; but they can be coded any time your provider injects Botox^® into certain facial/neck muscles.

Report Botox^® shots with one of the following codes, depending on encounter specifics:

• 64615 (Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine))
• 64616 (… neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis))

Guidance opportunity: During a Botox^® shot, the physician will almost certainly perform some sort of guidance to locate the target muscles. Report one of the following codes for guidance during a Botox shot:

• +95873 (Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure))
• +95874 (Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure))

Remember: Do not report more than one guidance code for 64615 or 64616.

Check Out This Clinical Example

Here’s a detailed report of a Botox^® injection from Burke. Read through the notes, and see if you can code it correctly.

Indication: Chronic migraine w/o aura, w/o status migrainosus, intractable
Injection preparation: 200 units of botulinum toxin was diluted in 4mL of sterile saline
Injection sites:
Bilateral frontalis: 2 spots, total of 10 units
Bilateral temporalis: 8 spots, total of 40 units
Bilateral occipitalis: 6 spots, total of 30 units
Bilateral cervical paraspinals: 4 spots, total of 20 units
Bilateral trapezius: 6 spots, total of 30 units = total 130 units used, 70 units discarded
EMG guidance used to locate injection sites
Post-injection complication: None, patient tolerated procedure well.
Post-injection instruction: patient has been advised to avoid hot shower and strenuous activity/exercising today to avoid adverse reaction. I advised the patient that if neurological issues were to develop, such as weakness, bowel or bladder control, or worsening pain, that they should present immediately to the closest emergency room.

For this encounter, you’d report 64615 and +95874 with G43.719 (Chronic migraine without aura, intractable, without status migrainosus) appended to represent the patient’s migraine.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC