Billing and Coding: Peripheral Nerve Blocks

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Peripheral Nerve Blocks.

**National Coverage**

Non-coverage for prolotherapy, joint sclerotherapy and ligamentous injections
with sclerosing agents is found in CMS Publication 100-03, _Medicare National
Coverage Determinations Manual_ , Section 150.7.

Effective January 21, 2020, all types of acupuncture including dry needling
for any condition other than chronic low back pain are non-covered by
Medicare. Medicare will cover acupuncture for Medicare patients with chronic
lower back pain within specific guidelines in accordance with NCD 30.3.3.

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed. For diagnostic tests, report the result of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported

**Based on Medicare rules, regulations, and National Correct Coding Initiative
(NCCI) edits** , CPT codes 64400-64530 (Peripheral nerve blocks-bolus
injection or continuous infusion) may be reported on the date of surgery if
performed for post-operative pain management only if the operative anesthesia
is general anesthesia, subarachnoid injection or epidural injection and the
adequacy of the intraoperative anesthesia is not dependent on the peripheral
nerve block. Peripheral nerve blocks codes should not be reported separately
on the same date of service as a surgical procedure if used as the primary
anesthetic technique or as a supplement to the primary anesthetic technique.
However 100-04 (Claims Processing Manual) Chapter 12 40 - Surgeons and Global
Surgery states under " _A. Components of a Global Surgical Package
"..."Postsurgical Pain Management - By the surgeon." _Similarly, CHAPTER II
ANESTHESIA SERVICES CPT CODES 00000-09999

FOR _NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES_
states _ "_Postoperative pain management services are generally provided by
the surgeon who is reimbursed under a global payment policy related to the
procedure and shall not be reported by the anesthesia practitioner unless
separate, medically necessary services are required that cannot be rendered by
the surgeon. The surgeon is responsible to document in the medical record the
reason care is being referred to the anesthesia practitioner." Thus any such
additional nerve blocks must not only be properly documented for why they
cannot be rendered by the surgeon, but also would be quite rare.

Use of physical medicine and rehabilitation CPT/HCPCS codes (97032, 97139,
G0282, G0283) for treatment of neuropathies or peripheral neuropathies caused
by underlying systemic diseases is inappropriate.

Injection therapies for tarsal tunnel syndrome (which include any so-called
"Baxter's injections") and for Morton's neuroma (CPT code 64455) do not
involve the structures described by CPT code 20550 and 20551 or direct
injection into other peripheral nerves but rather the focal injection of
tissue surrounding a specific focus of inflammation on the foot.

Injections for plantar fasciitis are addressed by CPT code 20550, not CPT code
64450. Injections for calcaneal spurs are addressed as are other tendon
origin/insertions by CPT code 20551. Injections to include both the plantar
fascia and the area around a calcaneal spur, are to be reported using only CPT
code 20551 with a unit of service of "1".

"Dry needling" of ganglion cysts, ligaments, neuromas, peripheral nerves,
tendon sheaths and their origins/insertions, or any tissue are non-covered
procedures.

**Documentation Requirements  
  
** The medical record documentation maintained by the performing provider must
clearly support the medical necessity of the service being billed. The
documentation supporting the service must be included in the patient's medical
record. This information is usually found in the history and physical,
office/progress notes, hospital notes, and/or procedure report. Medical
records must be available and submitted upon request for review.  
  
Documentation must support the criteria for coverage as set forth in the
"Indications and Limitations of Coverage and/or Medical Necessity" section of
the LCD.  
  
Assessment of the outcome of this procedure depends on the patient's
responses, therefore documentation should include:  
  
 Whether the block was a diagnostic or therapeutic injection  
 Pre- and post-procedure evaluation of patient  
 Patient education

**Utilization Guidelines**  
  
More than three injections per anatomic site (specific nerve, plexus or branch
as defined by the CPT code description) in a six month period will be denied.  
  
It is unusual that more than two nerves would need to be blocked at any one
session. If more than two nerves are blocked in one session, this may trigger
a medical review and the provider must document the medical necessity for more
than two blocks in the patient's medical record.  
  
It is expected that these services would be performed as indicated by current
medical literature and/or standards of practice. When services are performed
in excess of established parameters, they may be subject to review for medical
necessity. More than one unit of any code may be subject to prepayment review.