Billing and Coding: Peripheral Nerve Blocks

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:
Section 50 Payment for Anesthesiology Services

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.