Trigemial nerve injection

lcole7465

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I'm going between to codes for this injection for pain management: 64400 & 64402. The op report states: Flourosocopy was used to identify landmarks including right tempromandibular joint and the lateral pterygoid plate. A 25 gauge needle was passed atraumatically to to contact the lateral pterygoid plate. Placement was confirmed after instillation of 3 milliliters of omnipaque dye which demonstrated appropriate spread. At this point 4 mg of Dexamthasone & bupivicaine was slowly and incrementally injected after negative aspiration.

I'm leaning more towards coding: 64400. Anyone who has some input, it would be greatly appreciated.

Thanks
 

dwaldman

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I would request the doctor to document which nerve was targeted since the trigeminal nerve and facial nerve are in close proximity to the anatomy described in the procedure note. There are also techniques I saw described with an internet search of targeting the lateral pterygoid muscle. But since there are different reimbursement amounts the physician needs to identify what was targeted for treatment.
 
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