64400 Peripheral Nerve Blocks - FSIPP



PROPOSED/DRAFTFIRST COAST SERVICE OPTIONSMAC - PART BLOCAL COVERAGE DETERMINATIONLCD Database ID NumberDL29258 – FloridaDL29466 – Puerto Rico/Virgin IslandsContractor NameFirst Coast Service Options, Inc.Contractor Number09102 – Florida09202 – Puerto Rico09302 – Virgin IslandsContractor TypeMAC – Part BLCD TitlePeripheral Nerve BlocksAMA CPT Copyright StatementCPT codes, descriptions, and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.CMS National Coverage PolicyTitle XVIII of the Social Security Act, section 1862 (a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 50Primary Geographic JurisdictionFloridaPuerto Rico/Virgin IslandsOversight RegionRegion IOriginal Determination Effective Date02/02/2009 – Florida03/02/2009 – Puerto Rico/Virgin IslandsOriginal Determination Ending DateN/ARevision Effective DateMM/DD/YYYYRevision Ending DateMM/DD/YYYYIndications and Limitations of Coverage and/or Medical NecessityPeripheral nerves can be the cause of pain in a variety of conditions. Examples may include: post-herniorrhaphy pain (ilioinguinal/iliohypograstric/genitofemoral), iliac crest harvest syndromes (cluneal nerve, lateral femoral cutaneous nerve), carpal tunnel syndrome (median nerve), Morton’s neuroma, facial pain and headaches (trigeminal and occipital nerve). Peripheral nerve blocks may be used for both diagnostic and therapeutic purposes. Diagnostically, a peripheral nerve block allows the clinician to isolate the specific cause of pain in an individual patient. The injection of local anesthetic, with or without steroid may also provide an extended therapeutic benefit. If the patient does not achieve sustained relief, a denervation procedure via chemical, cryoneurolysis or radiofrequency may be effective at providing long term relief.[Indications:]Medicare will consider pPeripheral nerve blocks [will be considered]medically reasonable and necessary for conditions such as the following diagnostic and therapeutic purposes:When the patient’s pain appears to be due to a classic mononeuritis but the neuro-diagnostic studies have failed to provide a structural explanation, selective peripheral nerve blockade can usually clarify the situation. When peripheral nerve injuries/entrapment or other extremity trauma leads to complex regional pain syndrome. When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear. When a occipital nerve block is used to confirm the clinical impression of the presence of occipital neuralgia. Chronic headache/occipital neuralgia can result from chronic spasm of the neck muscles as the result of either myofascial syndrome or underlying cervical spinal disease. It may be unilateral or bilateral, constant or intermittent. Nerve injury secondary to a blow to the back of the head or trauma to the nerve from a scalp laceration can also cause this condition. Most commonly, it is caused by an entrapment of the occipital nerve in its course from its origin from the C2 nerve root to its entrance into the scalp through the mid portion of the superior nuchal line. Blockage of the occipital nerve can confirm the clinical impression of occipital neuralgia, particularly if the clinical picture is not entirely typical. If only temporary relief of symptoms is obtained, neurolysis of the greater occipital nerve may be considered via multiple techniques including pulsed radiofrequency, [radiofrequency]and cryoanalgesia. In addition, the lesser and third occipital nerves can be involved in the pathology of headaches, and can be treated in a similar manner.When the suprascapular nerve block is used to confirm the diagnosis of suspected entrapment of the nerve. Entrapment of the suprascapular nerve as it passes through the suprascapular notch can produce a syndrome of pain within the shoulder with weakness of supraspinatus and infraspinatus muscles. When the history and examination point to the diagnosis, a suprascapular nerve block leading to relief of pain can confirm it. This may be followed by injection of depository steroids that sometime provide lasting relief.When the trigeminal nerve is blocked centrally at the trigeminal ganglion, along one of the three divisions or at one of the many peripheral terminal branches (i.e., supraorbital nerve).Nerve blocks as preemptive analgesiaWhen a single injection peripheral nerve block provides post-surgical pain controlduring the transition to oral analgesicsin those procedures which cause severe pain normally uncontrolled by oral analgesicsin cases otherwise requiring control with intravenous or parenteral narcotics.in cases where the patient cannot tolerate treatment with narcotics due to allergy or side effects, etc.When a continuous peripheral nerve block provides the same as above, and furthermore may provide extended (i.e. one to five or more days) relief as a result of chronic administration of anesthetic.Preemptive analgesia starts before surgery, and a presumption of medical necessity is being made before the fact. Therefore, based on generally accepted clinical standards and evidence in peer reviewed medical literature the surgical procedure must be of such nature that the patient would benefit from the preemptive analgesia.Based on Medicare rules, regulations, and Correct Coding Initiative (CCI) 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.Medical management using medications, behavioral therapy, and physical therapy should be used (when appropriate) in conjunction with peripheral nerve block. Injection of depository steroids, may offer only temporary relief. In some cases, neurolysis may be appropriate to provide lasting relief.[If the patient does not achieve progressively sustained relief with repeat injections, alternative therapeutic options should be explored.[Limitations:The signs and symptoms that justify peripheral nerve blocks should be resolved after one to three injections at a specific site. More that three injections per anatomic site in a six month period will be denied.More than two anatomic sites injected at any one session will be denied. If the patient does not achieve progressively sustained relief after receiving two to three repeat peripheral nerve block injections on the same anatomical site, then alternative therapeutic options should be explored.There is insufficient evidence to support the use of peripheral nerve blocks in the treatment of diabetic peripheral neuropathy.The use of nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases is not considered medically reasonable and necessary. Medical management using systemic medications is clinically indicated for the treatment of these conditions.At present, the literature and scientific evidence supporting the use of peripheral nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases is insufficient to warrant coverage. These procedures are considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases.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.]CPT/HCPCS Codes64400Injection, anesthetic agent; trigeminal nerve, any division or branch64402Injection, anesthetic agent; facial nerve64405Injection, anesthetic agent; greater occipital nerve64412Injection, anesthetic agent; spinal accessory nerve64413Injection, anesthetic agent; cervical plexus64415Injection, anesthetic agent; brachial plexus, single64416Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) 64417Injection, anesthetic agent; axillary nerve64418Injection, anesthetic agent; suprascapular nerve64420Injection, anesthetic agent; intercostal nerve, single64421Injection, anesthetic agent; intercostal nerves, multiple, regional block64425Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves64430Injection, anesthetic agent; pudendal nerve64445Injection, anesthetic agent; sciatic nerve, single64446Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement) 64447Injection, anesthetic agent; femoral nerve, single64448Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) 64449Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) 64450Injection, anesthetic agent; other peripheral nerve or branch[64455Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton’s neuroma)]ICD-9 Codes that Support Medical Necessity[Coverage for CPT codes 64400, 64402, 64405, 64412, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64445, 64446, 64447, 64448, 64449 is limited to the following:]053.12Postherpetic trigeminal neuralgia053.13Postherpetic polyneuropathy053.9Herpes zoster without mention of complication140.0-149.9Malignant neoplasm of lip, oral cavity, and pharynx150.0-159.9Malignant neoplasm of digestive organs and peritoneum160.0-165.9Malignant neoplasm of respiratory and intrathoracic organs170.0-176.9Malignant neoplasm of bone, connective tissue, skin, and breast179-189.9Malignant neoplasm of genitourinary organs190.0-199.2Malignant neoplasm of other and unspecified sites200.00-208.92Malignant neoplasm of lymphatic and hematopoietic tissue209.00-209.79Neuroendocrine tumors210.0-229.9Benign neoplasms230.0-234.9Carcinoma in situ235.0-238.9Neoplasms of uncertain behavior239.0-239.9Neoplasms of unspecified nature307.81Tension headache337.20-337.29Reflex sympathetic dystrophy (Chronic Regional Pain Syndrome)338.18Other acute postoperative pain350.1Trigeminal neuralgia350.2Atypical face pain353.9Unspecified nerve root and plexus disorder354.0Carpal tunnel syndrome354.4Causalgia of upper limb355.1Meralgia paresthetica355.6Lesion of plantar nerve (Morton’s metatarsalgia)355.71Causalgia of lower limb355.8Mononeuritis of lower limb, unspecified355.9Mononeuritis of unspecified site443.0Raynaud’s syndrome443.9Peripheral vascular disease, unspecified564.6Anal spasm569.42Anal or rectal pain625.9Unspecified symptom associated with female genital organs719.41Pain in joint, shoulder region719.42Pain in joint, upper arm719.43Pain in joint, forearm 719.44Pain in joint, hand719.45Pain in joint, pelvic region and thigh719.46Pain in joint, lower leg719.47Pain in joint, ankle and foot723.1Cervicalgia723.8Other syndromes affecting cervical region724.1Pain in thoracic spine724.2Lumbago724.4Thoracic or lumbosacral neuritis or radiculitis, unspecified726.0Adhesive capsulitis of shoulder726.5Enthesopathy of hip region729.2Neuralgia, neuritis, and radiculitis, unspecified784.0Headache786.52Painful respiration789.00-789.09Abdominal pain789.9Other symptoms involving abdomen and pelvis997.61Neuroma of amputation stump[Coverage for CPT code 64450 is limited to the following:053.12Postherpetic trigeminal neuralgia053.13Postherpetic polyneuropathy053.9Herpes zoster without mention of complication140.0-149.9Malignant neoplasm of lip, oral cavity, and pharynx150.0-159.9Malignant neoplasm of digestive organs and peritoneum160.0-165.9Malignant neoplasm of respiratory and intrathoracic organs170.0-176.9Malignant neoplasm of bone, connective tissue, skin, and breast179-189.9Malignant neoplasm of genitourinary organs190.0-199.2Malignant neoplasm of other and unspecified sites200.00-208.92Malignant neoplasm of lymphatic and hematopoietic tissue209.00-209.79Neuroendocrine tumors210.0-229.9Benign neoplasms230.0-234.9Carcinoma in situ235.0-238.9Neoplasms of uncertain behavior239.0-239.9Neoplasms of unspecified nature307.81Tension headache337.20-337.29Reflex sympathetic dystrophy (Chronic Regional Pain Syndrome)338.18Other acute postoperative pain350.1Trigeminal neuralgia350.2Atypical face pain353.9Unspecified nerve root and plexus disorder354.0Carpal tunnel syndrome355.1Meralgia paresthetica443.0Raynaud’s syndrome443.9Peripheral vascular disease, unspecified564.6Anal spasm569.42Anal or rectal pain625.9Unspecified symptom associated with female genital organs719.41Pain in joint, shoulder region719.42Pain in joint, upper arm719.43Pain in joint, forearm 719.44Pain in joint, hand719.45Pain in joint, pelvic region and thigh719.46Pain in joint, lower leg719.47Pain in joint, ankle and foot723.1Cervicalgia723.8Other syndromes affecting cervical region724.1Pain in thoracic spine724.2Lumbago724.4Thoracic or lumbosacral neuritis or radiculitis, unspecified726.0Adhesive capsulitis of shoulder726.5Enthesopathy of hip region784.0Headache786.52Painful respiration789.00-789.09Abdominal pain789.9Other symptoms involving abdomen and pelvis997.61Neuroma of amputation stumpCoverage for CPT code 64455 is limited to the following:355.6*Lesion of plantar nerve*Use ICD-9 code 355.6 for Morton’s metatarsalgia, neuralgia, or neuroma]Diagnoses that Support Medical NecessityN/AICD-9 Codes that DO NOT Support Medical NecessityN/ADiagnoses that DO NOT Support Medical NecessityN/ADocumentation 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 this 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 injectionPre- and post-procedure evaluation of patientPatient education]When preemptive analgesia is performed by a provider other than the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure, there must be a compelling patient care reason for the involvement of the additional provider. The rationale for this approach must be clearly documented in the medical record. Medical records must be available and submitted upon request.Utilization Guidelines[More than three injections per anatomic site in a six month period will be denied.More than two anatomic sites injected at any one session will be denied.]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.Sources of Information and Basis for DecisionCapdevila, X., Pirat, P., Bringuier, S., Gaertner, E., Singelyn, F., Bernard, N., Choquet, O., Bouazia, H., & Bonnet, F. (2005). Continuous peripheral nerve blocks in hospital wards after orthopedic surgery: A Multicenter prospective analysis of the quality of postoperative analgesia and complications in 1, 416 patients. Anesthesiology.103: 5: 921-3.Cohen, N.P., Levine, W.N., Marra, G., Polllock, R.G., Flatow, E.L., Brown, A.R. (2000).Indwelling interscalene catheter anesthesia in the surgical management of stiff shoulder: A report of 100 consecutive cases. Journal of Shoulder Elbow Surgery. 9: 268-74.[Dworkin, R.H., O’Connor, A.B., Kent, J., Mackey, S. C., Raja, S.N., Stacey, B.R., et al. (2013). Interventional management of neuropathic pain: NeuPSIG recommendations. Pain, , H., Steele, S., Neilsen, K.C., Tucker, M.S., Klein, S.M. (2005). Peripheral nerve blocks and continuous catheter techniques. (Anesthesiology Clinics of North America. 23 (1): 141-62.Gottschalk, A. Ochroch, E.E. (2003). Preemptive analgesia. What do we do now? Anesthesiology. 98(1): 280-281.Grabinsky, A. (2005). Mechanisms of Neural Blockade. Pain Physician. 8:411-416.Kissin, I. (2000). Preemptive analgesia. Anesthesiology. 93(4): 1138-1143Manchikanti, L., Singh, V., Kloth, D., Slipman, C.W., Jasper, J., Trescot, A.M., Varley, K.G., Alturi, S.L., Giron, C., Curran, M.J., Rivera, J., Baha, A.G., Bakhit, C.E., and Reuter, M.W. (2001). Inerventional techniques in the management of chronic pain. Pain Physician 4(1) 24-98.Manchikanti, L., Staats, P.S., Singh, V., Shultz, D.M., Vilims, B.D., Jasper, J.F., Kloth, D.S., Trescot, A.M., Hansen, H.C., Falasca, T.D., Raczz, G.B., Deer, T.R., et al. (2003). Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 6: 3-81.Miller, R.D. (2000). Miller: Anesthesia, 5th ed. Philadelphia: Churchill Livingstone.National Correct Coding Inititaive Policy (2012) Chapter 11,(B),4[National Correct Coding Initiative Policy Manual for Medicare Services, (2013) Chapter 11]National Guideline Clearinghouse. (2011). Evidence-based guideline: treatment of painful diabetic neuropathy. Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Retrieved on June 25, 2013 from Other Contractor(s) PoliciesStart Date of Comment PeriodMM/DD/YYYYEnd Date of Comment PeriodMM/DD/YYYYStart Date of Notice PeriodMM/DD/YYYYRevision HistoryRevision History number: R3Revision Number: 3Publication: LCR BYYYY-XXXExplanation of Revision : Major revisions were made throughout the entire LCD. The ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD has been revised to clarify indications versus limitations of coverage. In addition, the ‘CPT/HCPCS Codes’, ‘ICD-9 Codes that Support Medical Necessity’, ‘Documentation Requirements’, ‘Utilization Guidelines’ and ‘Sources of Information and Basis for Decision’ sections of the LCD were updated. The effective date of this revision is based on date of service.Revision History number: R2Revision Number: 2Publication: September 2013 ConnectionLCR B2013-089Explanation of Revision : Based on an external revision request , the LCD was revised under the “Indications and Limitations of Coverage and/or Medical Necessity” section of the LCD to align with the National Correct Coding Initiatiavie (NCCI) policy. The effective date of this revision is for dates of service on or after 01/01/2013.Revision History number: R1Revision Number:Start Date of Comment Period:Start Date of Notice Period:Revised Effective Date:1N/A10/01/200910/01/2009LCR B2009-098September 2009 UpdateExplanation of Revision:Annual 2010 ICD-9-CM Update. Added diagnosis code range 209.70-209.79. The effective date of this revision is based on date of service.Revision NumberStart Date of Comment Period:Start Date of Notice Period:Original Effective DateOriginalN/A12/04/200802/02/2009 – Florida03/02/2009 – Puerto Rico/Virgin IslandsLCR B2009-044FLLCR B2009-045PR/VIDecember 2008 UpdateThis LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).For Florida (00590) this LCD (L29258) replaces LCD L13845 as the policy in notice. This document (L29258) is effective on 02/02/2009.For Puerto Rico (00973) and Virgin Islands (00974) there was no previous LCD on this subject. This document (L29466) is effective on 03/02/2009.?Related DocumentsN/ALCD AttachmentsN/ADocument formatted: 09/04/2013 (KS/mp) ................
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