Neurosurgery Coding Alert

Hint: Follow site of needle insertion to select the right code.

When your physician treats a patient for occipital nerve pain, you'll need to know what your physician does to treat it and where exactly your physician inserts the needle for accurate claims. Read on for more tips on how to identify which nerve your physician treats and the services provided to arrive at the right codes.

Strengthen Your Occipital Anatomy Basics

You will come across three distinct sets of occipital nerves in the body, so you'll need to know that which one in specific your physician is treating. You report distinct codes for procedures on each nerve.

Coding connection: To get to the right code, you should know the origin of the nerves, the structures these nerves supply and their distribution, and also what are the common complaints due to involvement of these nerves in any pathology.

Identify nerve pathology: One common condition stemming from the involvement of the GON that you will often get to report is the occipital neuralgia. You report ICD-9 code 723.8 (Other syndromes affecting cervical region) for occipital neuralgia.

Note: When ICD-10 goes into effect, you'll report M53.82 (Other specified dorsopathies, cervical region) for occipital neuralgia.

You look for conditions like neck trauma (whiplash) (847.0, Sprains and strains of other and unspecified parts of back; neck) or tender neck points (723.1, Other disorders of cervical region; cervicalgia) in the procedure note to ascertain the cause of the headache for which your physician administered the injection. "The clinical history will often reveal focal trauma directly to the nerve region and on examination, patients will often describe unilateral numbness in the distribution of the nerve," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Select Right Codes for Specific Nerves

In case of occipital neuralgia, your physician will perform a block in an office setting without any radiologic guidance. You should code this as 64405 (Injection, anesthetic agent; greater occipital nerve). If the physician diagnoses LON involvement, your physician may perform a block for the LON without radiological assistance. You then report 64450 (Injection, anesthetic agent; other peripheral nerve or branch).

CPT® does not assign a specific code for LON block procedure. "CPT includes only a limited number of codes for injecting specific peripheral nerves. If one is not specified, like LON, then code 64450 is applied," says Przybylski.

The real challenge comes when your physician performs a block for the TON.

Best code for TON: You may report code 64490 (Injection(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) for the procedure on the TON.

Tip: The TON is neither anatomically nor functionally synonymous with the GON. Look carefully in the procedure notes what necessitated the physician to perform the block and where the needle was inserted for the procedure. Your physician may perform the block on either of the occipital nerves to either diagnose or treat the patient's headache. Your physician will record the medical history and do a clinical examination to narrow down the choice to block a particular occipital nerve.

Find Needle Insertion Site

Read in the procedure note to identify where your physician inserted the needle. This is going to be your prime clue to choosing the right code.

Examples: If you read in the procedure note that your physician inserted the needle near the midline at the back of the head, you will be reporting an injection for the GON. Similarly, an injection behind the ear is your hint for an LON procedure. If you read that the injection was given in the medial branch of C3, you report the procedure for TON. "Only the injection of the TON requires image-guidance, which may also help you differentiate when a C2-3 paraverterbal facet joint nerve is performed," says Przybylski.

Report 64490 for the Third Occipital Nerve

Since location dictates your choice of code, you confirm that 64490 is a right code for the injection performed on the TON. Since the descriptor of code 64490 rightly defines the single level procedure of injection on the 'paravertebral facet joint', you would report this code for the TON injection procedures.

Tip: Never use 64412 (Injection, anesthetic agent; spinal accessory nerve) to report the injections in the TON. Whereas TON is a sensory nerve, the spinal accessory nerve is the 11th cranial nerve. Hence, code 64412 does not qualify for the TON procedure.

Code for Additional Procedures

If your clinician administered sedation to facilitate the procedure for occipital nerve injection, you would report code 99144 (Moderate sedation services [other than those services described by codes 00100-01999] provided by the same physician performing the diagnostic ortherapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; age 5 years or older, first 30 minutes intra-service time).

Remember: You do not separately report the local anesthesia. Your clinician will administer local anesthesia into the overlying skin prior to administering the block. This helps to reduce the needle-track pain and ensures the patient is seated comfortably during the procedure.

Providing local anesthesia is included in the surgical procedure of TON. However, you can claim for reimbursement of the actual medication used for the actual block if your clinician bore the expense and performed the procedure in his office. You will need to check on your payer preferences for reimbursement of the medications. Typically, these medications have the suffix 'caine', e.g. lidocaine, mepivacaine, bupivacaine and/or ropivacaine. Medicare may deny the payment for these, while other payers may pay if you report J3490 (Unclassified drugs) for these blocks.

Follow Up the Follow-ups

Do not forget that your clinician may perform the block to diagnose occipital nerve pathology and then perform a more definitive step to treat the same. For example, your physician may perform a block and then request the patient to maintain a pain diary and return to the clinic for a check on the success of the block.

If the block provides desired relief, your clinician may decide to repeat the block or administer the block into another occipital nerve. "There is no difference in reporting these on subsequent visits as the global period is 0 days," says Przybylski.

Make sure you provide adequate documentation in support of this entire procedure. "Since the GON and LON injections are typically performed in the office, it is important to keep track of performance of an E&M service on the same day," says Przybylski. "If the decision to perform the block is based on the medical decision making performed at that visit, then the E&M service is separately reportable with the -25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service...) modifier.

On the other hand: If the patient is asked to specifically come to the office for the performance of the injection, the E/M service is considered bundled into the procedure code."