Pain Management Coding Alert

Nerve Blocks:

Keep Trigeminal, Occipital Blocks Separate

Published on Fri Oct 11, 2019

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GON blocks = 64405.

Some of the more common PM injections for patients with headaches and neck issues include anesthetic injections to the trigeminal and occipital nerves. Coders need to recognize each type of injection and be ready to code accordingly.

To submit a clean claim for this scenario, you must verify a number of details, including whether the block was trigeminal or occipital, as well as which of the three occipital nerves the provider blocked during the service.

Read on to find out the CPT^® codes you should report when the provider performs a trigeminal or occipital nerve block.

Use 64400 for Trigeminal Shots

You’ll report trigeminal nerve injections with 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch), says Judith L Blaszczyk RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kansas.

Anatomy: According to Blaszczyk, “the branches of the trigeminal nerve innervate a large area including the whole forehead, face, lateral regions of the head and the most upper part of the neck. The nerve runs from the skull, branching into three divisions that supply feeling to the forehead, the cheek and the lower jaw.”

For pain relief, the PM provider injects the affected nerve — usually with a combination of local anesthetic and steroids, explains Blaszczyk. In fact, CPT^® is changing the descriptors for 64450 and several other anesthetic injection codes so they include the use of steroids and anesthetics. (For more information, see the cover story of this issue, “CPT^® 2020: Several Injections Groups Shot Through With Changes.”)

This Trio of Codes Leads to Occipital Block Success

You may see three different occipital nerves in the medical documentation for an occipital nerve block. Check them out below to learn more.

GON: The greater occipital nerve (GON) originates from the posterior medial branch of the C2 spinal nerve and provides sensory innervations to the posterior area of the scalp extending to the top of the head.

One common condition stemming from the involvement of the GON that you will often see is the occipital neuralgia. Physicians typically inject the GON at the level of the superior nuchal line just above the base of the skull for occipital headaches or neck pain.

LON: The lesser occipital (LON) nerve begins at the lateral branch of the ventral area of the C2 and C3 spinal nerves. This nerve is tasked with innervating the area of the scalp and head posterior to the ears.

“The lesser occipital nerve is several inches away from the greater occipital nerve so these nerves are not reached through the same injection site,” according to CPT^® Assistant Vol. 26, No. 10. “The lesser occipital nerve is at the side of the head by the ear, whereas the greater occipital nerve is at the very back of the head.”

PM providers typically perform a LON injection behind the patient’s ear.

TON: The third occipital nerve (TON) is the superficial medial branch of C3 dorsal ramus. The TON is neither anatomically nor functionally synonymous with the GON.

Know Block Types, Head Off Confusion

If the physician treats the patient’s occipital neuralgia by administering an occipital nerve, you have several CPT^® code choices.

Code 64405: If the surgeon performs a GON block in an office setting without any radiologic guidance for the greater optical nerve, you should report 64405 (Injection, anesthetic agent; greater occipital nerve).

Code 64450: If the surgeon diagnoses LON involvement, he may perform a block for the LON without radiological assistance. You then report 64450 (Injection, anesthetic agent; other peripheral nerve or branch).

However, CPT^® does not assign a specific code for LON block procedure, so, 64450 doesn’t specifically refer to a block. “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 Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Code 64490: 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.

Caution: You should not separately report the local anesthesia with these occipital nerve block codes. The provider 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.

Use This Strategy for Nerve Destruction

If a nerve block is not enough to provide long-term pain relief for the patient, then the physician could then choose to perform nerve destruction.

If the surgeon performs radiofrequency (RF) destruction at the terminal end of the nerve, you should report 64640 (Destruction by neurolytic agent; other peripheral nerve or branch).