Four Questions That'll Take You To The Best Diagnosis & Injection Codes

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Don't let your coding turn into a headache if your neurologist or pain management specialist administers greater occipital nerve blocks. Verify specifics about the patient's headache and the service your provider offered to pinpoint the proper diagnosis and procedure codes every time.


Where's the occipital nerve?


The great occipital nerve (GON) originates from the posterior medial branch of the C2 spinal nerve and provides sensory innervations to the posterior area of the scalp extending to the top of the head. Doctors normally inject the GON at the level of the superior nuchal line just above the base of the skull for occipital headaches or neck pain.


Medical coding tip: Some physician practices include a small illustration in the chart that the physician can mark with various injection sites. Including this type of tool helps your doctor clearly document the injection location, which helps you select the proper nerve injection code and submit more spot on claims.


What type of headache does the patient have?


Your ...
... physician's documentation might cover notes ranging from "occipital headache" to "occipital neuralgia" to "cervicogenic headache. Your task is to ensure that you interpret the notes and assign the most correct diagnosis.


Occipital neuralgia: You have a more specific diagnosis to code when your provider documents occipital neuralgia. Greater occipital neuralgia produces an aching, burning, or throbbing pain or a tingling or numbness along the back of the head. You'll report diagnosis 723.8 (Other syndromes affecting cervical region).


Cervicogenic headache: The alphabetic index does not include a listing directing medical coders to review a specific ICD-9 code. Many coders use 784.0 (Headache) owing to a lack of a better option.


Which service did the provider carry out?


Physicians can opt to treat occipital nerve pain by administering a nerve block or eventually by ablating the nerve.


Nerve block: Administering a nerve block temporarily relieves the patient's pain. For a greater occipital nerve block, use 64405. Some insurance companies classify 64405 as experimental or investigational, so these might deny coverage. You should review coverage policies so that you know what to expect when filling your claim.


Nerve destruction: When more conventional treatments fail to provide long term pain relief, the doctor might go for nerve destruction. Whether you see the term ‘radiofrequency ablation' or ‘thermocoagulation' on the patient's chart, you have two code choices, depending on where the physician carried out the destruction. If he carried out RF destruction at the terminal end of the nerve, use 64640. If he carried out RF at the origination, submit 64626. However, verify that your provider destroyed the nerve instead of treating it with pulses. The pulsed treatment does not appear to destroy the nerve, which does away with 64640 and 64626. In its place, pulsed treatment falls under 64999 (Unlisted procedure, nervous system).


How do you handle bilateral injections?


When your provider administers bilateral GON injections, verify the patient's insurance company prior to completing your claim.


Reason: Most Medicare contractors want you to report bilateral procedures as a single line item with a single unit of service and modifier 50 (bilateral procedure) added. However, private payers often need two lines for bilateral claims:


Line 1 with the procedure code, modifier RT, and one unit of service
Line 2 with the procedure code, modifier LT, and one unit of service.


Note that Medicare reimburses bilateral procedures at 150 percent of the allowed amount, meaning you will get 100 percent reimbursement for the first injection and 50 percent reimbursement for the second injection.


For more specialty-specific articles to assist your pain management coding, sign up for a good Medical coding resource like Coding Institute.