SPG Block (64505 and 64400) using SphenoCath


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What is the correct way to bill for a SPG Block that is done with the SphenoCath device? The SphenoCath device rep provided the following response when I suggested the correct code was the unlisted code (64999) since the SphenoCath uses an intranasal approach to deliver topical lidocaine to the SPG and surrounding nerves.

SphenoCath Rep Response:
There apparently are CPT Assistant comments out there about the 64505 CPT code. The previous CPT Assistant inquiries stating that 64505 is not appropriate did not mention the SphenoCath® device and was not an accurate description of the procedure using the SphenoCath® device so we believe it is not dispositive on the issue of the correct code(s) to use. The inquiry describes using an unspecified “device” to “deliver” some “medication” though the nose. Based upon that generic description, the response was that 64505 was not an “appropriate” code without giving any reason why. We believe that the response given was not applicable to procedures using the SphenoCath® device for several reasons.

First, the inquiry did not specify the device. Second, the SphenoCath® device is used to inject anesthetic as the CPT code describes (not “deliver” it, which is not what the CPT code describes). Third, the inquiry described delivery of “medication” while the SphenoCath® injects anesthetic. Fourth, the inquiry does not specify that an SPG block (or Trigeminal nerve block) is being performed as is the case with a procedure using the SphenoCath® device.

Based upon the above, the inquiry and response do not appear to be addressing the SphenoCath® device at all but may in fact be addressing the Tx360 device from Tian Medical, which is completely different (both in physical properties and how it is used procedurally) from the SphenoCath® device.

Billing personnel occasionally claim that the SphenoCath® device does not qualify as an injection for purposes of CPT code 64400 or CPT code 64505. No insurance company has ever brought up that question in over 3 years of claims being submitted. The term injection is not defined for either 64400 or 64505 while it is defined for purposes of other CPT codes. Therefore, it is not possible to categorically state that a SphenoCath® device administration does not qualify as an injection for purposes of 64400 or 64505. The term injection means “any pressurized delivery of injectate by pump, drip, or pressurized piston syringe... through needle, catheter, or cannula into an IM, IV, SQ, potential space, or other body cavity." The SphenoCath® device certainly qualifies under that definition. It is also well known that there are a number of medical procedures that do not involve a percutaneous delivery that are nonetheless called injections (for example sub-Tenons injections using a cannula).

In addition, a consultant’s inquiry to the AMA’s Knowledgebase requesting a definition of injection for purposes of 64505 resulted in the AMA responding on February 11, 2015 as follows:

Response from: CPT KnowledgeBase - 02/11/2015 10:30 AM

This is written in response to your Electronic Inquiry (EI) #9167 referencing EI's 9104 and 9139. From a CPT coding perspective and based upon the facts provided in your electronic inquiry please be advised that your inquiry was forwarded to our CPT Specialty Advisor representing the American Academy of Pain Medicine. Based upon comments received from our physician advisor and in response to your question, "this description does meet the requirements for 64505."

It appears that the AMA is clearly acknowledging that the SphenoCath® device administered SPG block does qualify as an injection for purposes of 64505 (and by extension to CPT code 64400). In any event, the CPT code is clear that SPG blocks and Trigeminal nerve blocks have separate and clearly identified procedure codes which are to be used when these procedures are performed.


Local Chapter Officer
La Crosse
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SPG billing/reimbursement questions

Our facility is currently starting to do more SPG injections for migraines. I have a few questions that I would like to ask.

1) Which places out there currently perform these injections?
2) Which codes are billed?
3) Are you a clinic based facility or a hospital based facility?
4) Is the procedure done as unilateral or bilateral?
5) Which insurances cover this procedure if any at all?
6) What is your cost for this procedure - how much does the patient get billed?
7) Do you bill it through insurance or have the patient pre-pay for this service?

Thanks for any input or advice.