Piriformis muscle injection

scgcpc2002

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I have an op report that one of our pain MD's dictated....which I've never coded before. He stated he a right piriformis muscle injection under fluroscopy...Would this be a 64445 with 77003 or????
Thanks in advance.
 

elenax

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I would go for the 64445 as well, because the piriformis is
"A muscle in the pelvic girdle that is closely associated with the sciatic nerve."

Other option would be the 64450 which is other peripheral nerve or branch.

...and of course the 77003

hope this helps!!!
 

coderguy1939

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I think you may want to use 77002 for fluoroscopy in this instance. Check out CPT Assistant June 2008 on use of fluoroscopy.
 

DVoyles

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This is from a M'care B news issue:

NAS has also noted that providers have been using both CPT codes 64999 (unlisted procedure nervous system) and 64445 (Injection anesthetic agent; sciatic nerve, single) for the injection of the piriformis muscle and surrounding muscle groups. This is not the correct way to code. When the clinical notes reflect direct nerve block to the sciatic nerve, 64445 should be used. When the injection focus is in the piriformis muscle or surrounding muscle groups, 64999 should be used. When both of these codes are billed on the same date of service, 64999 will be denied.

Here is the link if you wish to read the entire article

https://www.noridianmedicare.com/shared/partb/bulletins/2007/241_nov/Magnetic_Resonance_Neurography_and_Piriformis_Injection.htm
 

karenpair

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Karen Pair CPC

I do not agree with 64445 or 64450 since these are blocking the nerve. The piriformis is a muscle so I have been using 20552 for trigger point in the muscle and 77002. I have read this is the way to code in one of our pain or ortho alerts.
 

hgolfos

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Karen and SS62,

I agree that a piriformis "muscle" injection is not a nerve block. The problem with this is: billing 20552 is not considered a medical necessity when billed with the dx code 355.0 piriformis syndrome, which is the common dx I'm seeing. Any ideas on another code choice? Here are some that I have seen canvassed:

64999 - This code is denied by almost every payer there is... and is technically incorrect because it is an unlisted nervous system procedure.

20550 - may be correct technically, but cheats the physician out of reimbursement because the piriformis injection is more difficult to perform than this.

20552 - as above, the dx does not est. medical necessity

64445 - this is specifically a nerve injection and if the physician does not document blocking the nerve it is innappropriate to use it.

64450 - peripheral nerve. i read on one site that a peripheral nerve does run through the piriformis muscle, but I'm not convinced that this is appropriate either.

Aaaack!
 

dsheets07

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You should not change the procedure based on coverage criteria! You must code for the procedure that was actually performed. Piriformis "muscle" injection is a trigger point and should be billed as 20552 (if multiple injections are done). Perhaps you should query your documentation or your provider for additional diagnosis that might meet your medical necessity or educate the providers on what documentation is required for coverage-but you should never change the procedure or diagnosis simply for coverage.
 

hgolfos

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Thanks for your input. I certainly wasn't implying that I should "change" the code based on coverage criteria. The fact of the matter is, not everyone agrees that 20552 is the correct code for a piriformis injection. There is not a code specifically for this, and there is no official guidance that I can find anywhere. I have done quite a bit of research on it, and frankly the jury is still out on how to code these.
 
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We diagnose using 729.1 primary, 355.0 second for Medicare payers. We also bill 20552 for injection into the piriformis muscle which is usually documented as part of the procedure note.
 
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