antoniamay
Networker
I had a coding question I was hoping someone can help me clear up because it’s clear there is not really a ton of guidance online on this procedure available. I am wondering the correct code for Intercostobrachial Nerve Block since it is done in the upper arm I can see either 64415 or 64450 being the correct code - I cannot see 64420 being the correct code based on the information below.
64415 - Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed - The physician injects one or more anesthetic agents and/or steroids near the brachial plexus to relieve pain and inflammation in 64415. The physician draws a local anesthetic and/or steroid into a syringe and injects it into a targeted area near the brachial plexus, approached in one of several locations: interscalene, superior trunk, supraclavicular, infraclavicular, or axillary.
64420 - Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level - The physician injects one or more anesthetic agents and/or steroids near the intercostal nerves, which are located underneath the ribs, to alleviate pain and inflammation often caused by a herpes zoster infection (shingles) or a surgical incision.
64450 - Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch - The physician injects one or more anesthetic agents and/or steroids near an affected peripheral nerve or branch to control pain and inflammation or to aid in diagnosis and treatment. The physician draws an anesthetic agent and/or steroid into a syringe and injects it into the targeted area. This code is used to report nerve blocks of other nerves not specifically listed in this section.
The intercostobrachial nerve arises from the second thoracic (T2 and occasionally T1) nerve root. As such, it is not a component of the brachial plexus and is, therefore, not anesthetized by any brachial plexus approach. Along with the medial cutaneous nerve of the arm (an intermediary branch of the medial cord), the intercostobrachial nerve provides cutaneous sensation to the upper half of the medial/posterior arm. It also innervates a portion of the anterior axilla.
Selective upper extremity nerve blocks can be useful supplements to brachial plexus blocks. Supraclavicular, suprascapular, and intercostobrachial nerve blocks are valuable adjuncts to the anesthesia and/or analgesia primarily provided by a plexus block or general anesthesia.
So if you selected 64450 as the code for Intercostobrachial CMS states that “CPT code 64450 is NOT medically necessary when billed with any other CPT code in the GROUP 2 Codes (includes 76942) listed PLUS any one of the GROUP 1 (Includes 64415 and G89.18 – Other acute postprocedural pain) diagnosis listed in the ICD-10 Codes that DO NOT Support Medical Necessity section below.” but this article isn't for Surgery.....
Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy
Another thing I found that was interesting on this is Aetna’s policy which states that they recommend 64415 for the Intercostobrachial – which makes sense because UptoDate says this is the axillary crease and Encoder says that 64415 includes axillary.
Aetna Nerve Block
So now for my question:
I am wondering if what both CMS and Aetna are saying, since the MUE for 64415 is 1 and since 64450 isn’t medically necessary with 64415, 76942 and G89.18 (I hope I am reading that right) that if an anesthesiologist was to supplement the brachial plexus block with Intercostobrachial block that only 1 is covered and we should not be paying for the Intercostobrachial when billed with the Brachial Plexus Block is more of a MUE denial and that the correct code may actually be 64415 for the Intercostobrachial Nerve block.
My other question is there seems to be a lot of data out now including from anesthesiologists that the use of Intercostobrachial nerve blocks for the prevention of tourniquet pain in upper extremity surgery that there is a modest failure rate and even where tourniquet time is greater than 2 hours this can be controlled with routine intraoperative sedatives like fentanyl which would be (01610-01680)
http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2021&index=18&absnum=6499
What are you all using and going by out there for Intercostobrachial and Interscalene blocks?
64415 - Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed - The physician injects one or more anesthetic agents and/or steroids near the brachial plexus to relieve pain and inflammation in 64415. The physician draws a local anesthetic and/or steroid into a syringe and injects it into a targeted area near the brachial plexus, approached in one of several locations: interscalene, superior trunk, supraclavicular, infraclavicular, or axillary.
64420 - Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level - The physician injects one or more anesthetic agents and/or steroids near the intercostal nerves, which are located underneath the ribs, to alleviate pain and inflammation often caused by a herpes zoster infection (shingles) or a surgical incision.
64450 - Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch - The physician injects one or more anesthetic agents and/or steroids near an affected peripheral nerve or branch to control pain and inflammation or to aid in diagnosis and treatment. The physician draws an anesthetic agent and/or steroid into a syringe and injects it into the targeted area. This code is used to report nerve blocks of other nerves not specifically listed in this section.
The intercostobrachial nerve arises from the second thoracic (T2 and occasionally T1) nerve root. As such, it is not a component of the brachial plexus and is, therefore, not anesthetized by any brachial plexus approach. Along with the medial cutaneous nerve of the arm (an intermediary branch of the medial cord), the intercostobrachial nerve provides cutaneous sensation to the upper half of the medial/posterior arm. It also innervates a portion of the anterior axilla.
Selective upper extremity nerve blocks can be useful supplements to brachial plexus blocks. Supraclavicular, suprascapular, and intercostobrachial nerve blocks are valuable adjuncts to the anesthesia and/or analgesia primarily provided by a plexus block or general anesthesia.
So if you selected 64450 as the code for Intercostobrachial CMS states that “CPT code 64450 is NOT medically necessary when billed with any other CPT code in the GROUP 2 Codes (includes 76942) listed PLUS any one of the GROUP 1 (Includes 64415 and G89.18 – Other acute postprocedural pain) diagnosis listed in the ICD-10 Codes that DO NOT Support Medical Necessity section below.” but this article isn't for Surgery.....
Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy
Another thing I found that was interesting on this is Aetna’s policy which states that they recommend 64415 for the Intercostobrachial – which makes sense because UptoDate says this is the axillary crease and Encoder says that 64415 includes axillary.
Aetna Nerve Block
So now for my question:
I am wondering if what both CMS and Aetna are saying, since the MUE for 64415 is 1 and since 64450 isn’t medically necessary with 64415, 76942 and G89.18 (I hope I am reading that right) that if an anesthesiologist was to supplement the brachial plexus block with Intercostobrachial block that only 1 is covered and we should not be paying for the Intercostobrachial when billed with the Brachial Plexus Block is more of a MUE denial and that the correct code may actually be 64415 for the Intercostobrachial Nerve block.
My other question is there seems to be a lot of data out now including from anesthesiologists that the use of Intercostobrachial nerve blocks for the prevention of tourniquet pain in upper extremity surgery that there is a modest failure rate and even where tourniquet time is greater than 2 hours this can be controlled with routine intraoperative sedatives like fentanyl which would be (01610-01680)
http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2021&index=18&absnum=6499
What are you all using and going by out there for Intercostobrachial and Interscalene blocks?