Wednesday, September 21, 2016

CPT CODE 64450, 64415, 64405, 01630, 01820, 01400

cpt code and description

64450 - Injection, anesthetic agent; other peripheral nerve or branch - average fee amount - $80 - $100

64405 INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE

64415 - Injection, anesthetic agent; brachial plexus, single Average fee amount - $110 - $130

 01630 – Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified.

 01820 – Anesthesia for all closed procedures on radius, ulna, wrist, or hand bones Only report 01630 – use time for both procedures.

 01382 Anesthesia for diagnostic arthroscopic procedures of knee joint procedures of knee joint

 01400 Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified



• Injection, anesthetic agent to somatic nerves (64400-64450) will be allowed with anesthesia services (00100-01953)


PERIPHERAL NEUROPATHY

• Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain.

• The use of imaging guidance (i.e. ultrasound, CT, or fluoroscopic guidance) in conjunction with these non-covered injections is also considered not medically necessary.

• The use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not medically reasonable and necessary. These procedures are considered investigational. Medical management using systemic medications is clinically indicated for the treatment of these conditions.

Response

The intention of the LCD is to limit the use of nerve blocks or injections for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases, this LCD only includes the CPT code 64450, other peripheral nerve or branch and does not apply to nerve injections that have a specific code. For example 64420 intercostal nerve single, 64421 intercostal nerves multiple regional block, 64405 greater occipital nerve or any other specific nerve injection.


Comment

One Commenter suggested removal of ICD-9 code 719.47, Pain in joint ankle and foot, because this is a code that could be used for a payable services such as nerve blocks to facilitate physical therapy.

Another commented: We all agree that nerve blocks are not appropriate for peripheral neuropathy. They are however sometimes appropriate for peripheral neuralgias. There are CPT codes for some but not all nerve blocks done for peripheral neuralgias. For example, there are specific codes available for trigeminal, occipital, suprascapular, intercostal, ilioinguinal,
pudendal, sciatic and femoral nerves. However, some nerves that are commonly blocked do not have specific CPT codes including the lateral femoral cutaneous nerve (meralgia paresthetica) the genitofemoral nerve (groin and genital pain), and interdigital nerves (neuroma). We use the 64450 ‘other peripheral branch’ CPT code for these less common nerve blocks.

The LCD seems to state that CPT 64450 ‘other peripheral nerve’ will not be paid at all for any block. I agree this code should not be paid for ICD-9 diagnoses of peripheral neuropathy (249, 250, 356, 357) but it should continue to be paid for ICD-9 diagnoses of peripheral neuralgia (354, 355,729.2).

Injections for Post-Operative Pain Control

When a patient is to receive an Injection or has a Catheter placed during an Arthroscopic Shoulder surgical procedure for control of post-operative pain, there are certain requirements which must be met in order to bill the   injection/Catheterization procedure separately.


o Do not bill to Medicare.

o The Injection/Catheterization procedure must be performed by a different physician (usually the anesthesiologist) from the surgeon who performs the ortho.



scope surgery.

o There must be a separate Procedure Report for the Post-Op Injection/ Catheterization procedure (it cannot be part of the surgeon’s OP Report or part of the Anesthesia Record).

o The Block must not be the only anesthesia for the case.

o If there is a separate report for the Injection/Catheterization procedure and the Injection/Catheterization procedure was performed by a different physician, you may bill for the Injection/Catheterization procedure. Use a different claim form from the Shoulder surgery procedure and bill the Injection/Catheterization procedure claim in the name of the anesthesiologist (or other physician) who performed the Injection/Catheterization procedure.

o Codes for billing Injection/Catheterization Shoulder post-operative pain procedures:

1. 64415 – Brachial Plexus Block (also use this code for an Interscalene Block) for a Single Injection OR

2. 64416 – Brachial Plexus Infusion by Catheter using a Pain Pump Medicare has issued specific guidance that in most cases they consider Injections performed routinely for Post-Operative Pain Control to be bundled into the orthopedic surgeon’s global services (even when the Injection is performed by a different physician), so we would recommend not billing them to Medicare.

If Injections are given for Post-Op Pain Control after Knee Surgery, the 64447 code for a Femoral Nerve Block Injection or code 64448 for a Femoral Block by Catheter using a Pain Pump would be used. Use code 64450 for Blocks for Ankle and Foot procedures.


For example, when an avulsion of a nail plate (CPT code 11730) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 11730 when the same physician performs both procedures



For example, when a small joint or bursa arthrocentesis, aspiration and/or injection (CPT code 20600) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 20600 when the same physician performs both procedures.

We require supporting clinical documentation in the use of Modifier 59 for a group of select National Correct Coding Initiatives (NCCI) edits. The documentation should substantiate the use of Modifier 59 in requesting separate reimbursement. This documentation should be supplied with the initial claim. We are adding 49 code pairs to the existing list. The code pairs that are being added are:

Denied Code Paid Code

64415 00450 64416 01630 64445 01480 64448 01480
64415 01400 64416 01638 64447 01320 64450 01400
64415 01480 64416 01710 64447 01392 64450 01402
64415 01610 64416 01740 64447 01400 64450 01464
64415 01620 64416 01810 64447 01402 64450 01470
64415 01630 64416 01830 64447 01464 64450 01472
64415 01638 64445 01320 64447 01470 64450 01480
64415 01710 64445 01392 64447 01472 64450 01630
64415 01740 64445 01400 64447 01480 64450 01810
64415 01810 64445 01402 64448 01320 64450 01830
64415 01830 64445 01464 64448 01392
64416 00450 64445 01470 64448 01400
64416 01610 64445 01472 64448 01402

Billing and Coding Guidelines

 Anesthesia service included in surgical procedure

For example, when an avulsion of a nail plate (CPT code 11730) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 11730 when the same physician performs both procedures

 Anesthesia service included in surgical procedure

For example, when a small joint or bursa arthrocentesis, aspiration and/or injection (CPT code 20600) is performed, anesthesia may be provided by the surgeon using a digital nerve block (CPT code 64450). Because this type of anesthesia provided by the surgeon performing the procedure is not separately payable, CPT code 64450 is bundled into CPT code 20600 when the same physician performs both procedures.

Reimbursement question

1. Is the allowance of code 66415 included in the allowance of 01630-QK?

2. Is the requestor entitled to reimbursement for code 66415?



Findings

1. 28 Texas Administrative Code §134.203(a)(5) states “Medicare payment policies” when used in this section, shall mean reimbursement methodologies, models, and values or weights including its coding, billing, and reporting payment policies as set forth in the Centers for Medicare and Medicaid Services (CMS) payment policies specific to Medicare.”

28 Texas Administrative Code 134.203(b)(1) states “For coding, billing, reporting, and reimbursement of professional medical services, Texas workers’ compensation system participants shall apply the following: (1) Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; bonus payments for health professional shortage areas (HPSAs) and physician scarcity areas (PSAs); and other payment policies in effect on the date a service is provided with any additions or exceptions in the rules.”

According to the explanation of benefits, the respondent denied reimbursement for CPT code 64415 based upon reason code “97.”

The 2014 National Correct Coding Initiatives Manual, Chapter 2, states “A peripheral nerve block injection (CPT codes 64XXX)for postoperative pain management may be reported separately with an anesthesia 0XXXX code only if the mode of intraoperative anesthesia is general anesthesia, subarachnoid injection, or epidural injection, and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block injection.” The requestor indicated the nerve block was for post-operative pain management.

Per CCI edits, CPT code 64415 is not bundled to 01630-QK; therefore, reimbursement is recommended.



2. Per 28 Texas Administrative Code §134.203(c)(1)(2), “To determine the MAR for professional services, system participants shall apply the Medicare payment policies with minimal modifications. (1) For service categories of Evaluation & Management, General Medicine, Physical Medicine and Rehabilitation, Radiology, Pathology, Anesthesia, and Surgery when performed in an office setting, the established conversion factor to be applied is $52.83. For Surgery when performed in a facility setting, the established conversion factor to be applied is $66.32.

(2) The conversion factors listed in paragraph (1) of this subsection shall be the conversion factors for calendar year 2008.

Subsequent year's conversion factors shall be determined by applying the annual percentage adjustment of the Medicare economic Index (MEI) to the previous year's conversion factors, and shall be effective January 1st of the new calendar year. The following hypothetical example illustrates this annual adjustment activity if the Division had been using this MEI annual percentage adjustment: The 2006 Division conversion factor of $50.83 (with the exception of surgery) would have been multiplied by the 2007 MEI annual percentage increase of 2.1 percent, resulting in the $51.90 (with the exception of surgery) Division conversion factor in 2007.”

Anesthesia Services CPT Code 01400-CZ 

Background

1. 28 Texas Administrative Code §133.307 sets out the procedures for resolving medical fee disputes.

2. 28 Texas Administrative Code §134.203 set out the fee guideline for the reimbursement of workers’ compensation professional medical services provided on or after March 1, 2008.

3. The services in dispute were reduced/denied by the respondent with the following reason codes:

? BL-This bill is a reconsideration of a previously reviewed bill. Allowance amounts do not reflect previous payments.

Issues

1. Is the requestor entitled to additional reimbursement for code 01400-CZ?

Findings

1. 28 Texas Administrative Code §134.203(a)(5) states, “Medicare payment policies” when used in this section, shall mean reimbursement methodologies, models, and values or weights including its coding, billing, and reporting payment policies as set forth in the Centers for Medicare and Medicaid Services (CMS) payment policies specific to Medicare.”

28 Texas Administrative Code 134.203(b)(1) states, “For coding, billing, reporting, and reimbursement of professional medical services, Texas workers’ compensation system participants shall apply the following: (1) Medicare payment policies, including its coding; billing; correct coding initiatives (CCI) edits; modifiers; bonus payments for health professional shortage areas (HPSAs) and physician scarcity areas (PSAs); and other.

28 Texas Administrative Code §134.203(c)(1) states, “…To determine to MAR for professional services, system participants shall apply the Medicare payment policies with minimal modification…For service categories of Evaluation & Management, General Medicine, Physical Medicine and Rehabilitation, Radiology, Pathology, Anesthesia, and Surgery when performed in an office setting, the established conversion factor to be applied is $53.68…”

The requestor billed CPT code 01400-CZ defined as “Anesthesia for Procedures on the Knee and Popliteal Area.”

The requestor billed the disputed anesthesiology service using the “CZ” modifier that is described as “CRNA service: without medical direction by a physician.”

To determine the MAR the following formula is used: (Time units + Base Units) X Conversion Factor = Allowance.

The Division reviewed the submitted medical bill and finds the anesthesia was started at 0909 and ended at 1158, for a total of 169 minutes. Per Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners, Payment for Anesthesiology Services Section (50)(G) states, “Actual anesthesia time in minutes is reported on the claim. For anesthesia services furnished on or after January 1, 1994, the A/B MAC computes time units by dividing reported anesthesia time by 15 minutes. Round the time unit to one decimal place.” Therefore, the requestor has supported 169/15 = 11.26 = 11.3.

The base unit for CPT code 01400 is 4.

The DWC Conversion Factor for 2015 is $56.2.

The MAR for CPT code 01400 is: (Base Unit of 4 + Time Unit of 11.3 X $56.2 DWC conversion factor = $859.86. Previously paid by the respondent is $719.36. The difference between the MAR and amount paid is $140.50. The requestor is seeking a lesser amount of $138.81, this amount is recommended for reimbursement.

Conclusion

For the reasons stated above, the Division finds that the requestor has established that additional reimbursement is due. As a result, the amount ordered is $138.81.

01400 Open procedures on knee joint; nos


Payment Facility Payment APC Code APC Payment

64405 Injection, anesthetic agent; greater occipital nerve $103.11 $65.52 0206 $372.62
64413 Injection, anesthetic agent; cervical plexus $131.39 $84.49 0206 $372.62
64415 Injection, anesthetic agent; brachial plexus, single $119.22 $66.23 0206 $372.62
64417 Injection, anesthetic agent; axillary nerve $131.03 $72.32 0206 $372.62
64418 Injection, anesthetic agent; suprascapular nerve $149.29 $79.12 0206 $372.62
64420 Injection, anesthetic agent; intercostal nerve, single $113.85 $69.45 0206 $372.62
64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block $152.51 $94.16 0207 $671.80
64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves $134.25 $95.95 0206 $372.62
64445 Injection, anesthetic agent; sciatic nerve, single $137,84 $74.47 0206 $372.62
64447 Injection, anesthetic agent; femoral nerve, single n/a $67.31 0206 $372.62
64450 Injection, other peripheral nerve or branch $79.99 $46.90 0206 $372.62

Regional anesthesia

 Bill the agency the appropriate procedure code (e.g. epidural CPT code 62319) with no time units and no anesthesia modifier. The agency determines payment by using the procedure’s maximum allowable fee, not anesthesia base and time units.

Local nerve block CPT code 64450 (other than digital and metacarpal) for subregional anatomic areas (such as the hand, wrist, ankle, foot and vagina) is included in the global surgical package and is not paid separately.

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