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  1. Question SpenoCath
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    My physician has started performing SpenoCath in the office. We billed the following codes and I just want to make sure the information that I was given is accurate for the coding.


    With Dx: R51, G43.101

    We are billing to Medicare. Any help would be greatly appreciated.


  2. #2
    J2001 might not work since it is for intravenous infusion, but the carrier might be requesting the use of that code based the NDC crosswalk that they might utilized regardless of the code descriptor. The AMA stated in 2014 that a transnasal approach using a "device to deliver medication" was unlisted code, but I am not specifically familiar with the Sphenocath although it appears it is a injection through a catheter. There is AAPC forum thread that is pretty informative from 2016 where the rep from Sphenocath and could merit further published material regarding a transnasal approach utilizing 64505 versus standard needle puncture. Although one calls for an injection, what seems to be the best thing that should be considered would be what is the safest option and does the transnasal approach meet that by being more minimally invasive. To bill 99213 in addition it would require significantly separate E/M, if they are schedule for a procedure that might not be met.

    Injection, lidocaine HCl for intravenous infusion, 10 mg

    AMA CPT Assistant July 2014
    Surgery: Nervous System
    Question: My physicians are using a device to deliver medication through the nose when a sphenopalatine ganglion block is performed under fluoroscopic guidance for patients with
    migraine headaches. What is the appropriate code(s) to report?

    Answer: There is no specific CPT code that accurately describes this service. The code set includes code 64505, which describes the injection of the sphenopalatine
    ganglion; however, it is inappropriate to report this code. Therefore, the unlisted code 64999, Unlisted procedure, nervous system, should be reported. When reporting an
    unlisted code to describe a procedure or service, it may be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate
    description of the nature, extent, and the need for the procedure, as well as and the time, effort, and equipment necessary to provide the service.


    "That 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.
    Last edited by dwaldman; 10-04-2018 at 11:33 PM.

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