AMA 2015 CPT Changes states 64486-64489 include image guidance when performed. You would not separately report imaging guidance regardless if you are billing for the physician service or facility/technical portion.
AMA CPT Changes 2015
Rationale
Four codes (64486-64489) have been established to report administration of local anesthetic for postoperative pain control and abdominal wall analgesia, including imaging guidance when performed. Because more than 50% of the time these services are typically performed bilaterally, codes 64486 and 64487 are intended to report the transversus abdominis plane (TAP) block performed unilaterally, and codes 64488 and 64489 are intended to report bilateral services.
Clinical Example (64488 )
A 45-year-old female undergoes laparoscopy cholecystectomy under general anesthesia. She is at risk for postoperative pain. In order to provide postoperative pain control, bilateral TAP blocks are placed at the request of the surgeon.
Description of Procedure (64488 )
Place a linear, high-frequency ultrasound transducer in an axial (transverse) plane, above the iliac crest within the region of the anterior axillary line. Using continuous ultrasound guidance, identify the layers of the abdominal wall: the external oblique (superficial), the internal oblique, and the transversus abdominis muscles. Anesthetize the skin at the proposed entry site with a small amount of local anesthetic via a small-gauge needle (27-gauge). Insert a 100-mm, 22-gauge short-beveled block needle in plane with the transducer. While advancing under live ultrasound guidance, feel two distinct "pops" as the needle passes through the external oblique fascia and then the internal oblique fascia. Now, the needle is in the TAP plane between the internal oblique and the transversus abdominis muscles. Once correct needle position is obtained, perform aspiration of the needle to confirm the absence of blood. Following negative aspiration, administer a small test dose of local anesthetic, monitor the patient's vital signs, and question the patient for symptoms of intravascular local anesthetic injection. If there are no signs or symptoms of intravascular then incrementally inject 20 ml of local anesthetic with verification of a hypoechoic fluid pocket immediately deep to the hyperechoic fascial plane between the internal oblique and the transversus abdominis. After completion of the injection, remove the needle
