Postoperative Pain Block by Surgeon

Question:

This question may fall outside the interventional pain questions typically submitted to KZA.

Our surgeon is performing a total knee replacement and a postoperative pain block on a Medicare patient. Can we report the block in addition to the total knee arthroplasty procedure?

Answer:

Thank you for your submitted question!

Both CPT and CMS consider postoperative pain management by the physician performing the surgical procedure to be included in the global surgical package and not separately reportable.

Based on the submitted scenario, the surgeon's appropriate coding is 27447 for the total knee arthroplasty.

*This response is based on the best information available as of 5/22/25.

Clarifying Nerve Injection Coding: CPT 64451 vs. 64450

Question:

Hi KZA, I am new to pain management coding. If I’m injecting the L5, S1, S2, and S3 nerves, do all four have to be injected in order to report code 64451 appropriately? Could code 64451 still be reported if only one or two nerves are injected?

Answer:

All four nerves must be injected in order to report code 64451, Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (i.e., fluoroscopy or computed tomography).

The injection targets the L5 dorsal ramus nerve at the junction of the sacral ala and S1 superior articular process. In turn, the S1, S2, and S3 nerves are injected at the posterior lateral foramen of the S1, S2, and S3 foramen. CPT 64451 has an MUE of 1.

If only one or two nerves or branches were injected, code 64450, Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch, may be reported with one or two units, respectively. Follow your individual third-party payor’s guidelines for appropriate modifier usage when each subsequent unit of 64450. CPT 64450 has an MUE of 10.

*This response is based on the best information available as of 4/10/25.

Chronic Pain Management G Codes

Question:

I'm struggling to understand the guidelines for HCPCS code G3002 and G3003. Is there any guidance you could provide?

Answer:

CMS's MLN006764 September 2024 provides guidance on the appropriate use of Chronic Pain Management (CPM) HCPCS codes G3002 and G3003. Medicare defines chronic pain as “persistent, or current pain lasting longer than three months.”

The HCPCS codes are used for reporting "chronic pain management” and treatment monthly bundle including:

• Diagnosis

• Assessment and monitoring diagnosis

• Administration of a validated pain rating scale or tool

• Development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes;

• Overall treatment management; facilitation and coordination of any necessary behavioral health treatment;

• Medication management;

• Pain and health literacy counseling;

• Any necessary chronic pain related crisis care;

• Ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate.

Criteria and documentation requirements

The initial visit must be face-to-face visit for at least 30 minutes provided by a physician or other qualified health professional. 30 minutes must be met or exceeded to bill for G3002.

G3003 can be added for each additional 15 minutes of chronic pain management and treatment personally provided by a physician or other qualified health care professional, per calendar month. The entire 15 minutes must be utilized in to report.

You must develop and maintain a person-centered plan.

You must provide and document the elements listed in the code bundle to the first month for each patient. Subsequent months do not require all listed components.

Although this code was created by CMS, we recommend you reach out to your commercial payors as they may reimburse for them as well.

G3002 is billed once per calendar month. G3003 is billable for as many times as medically necessary within the calendar month and calculated in 15-minute increments.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

*This response is based on the best information available as of 3/27/25.

Should the Acupuncturist be Present

Question:

When a patient receives acupuncture for 30 minutes, does there need to be personal one-on-one contact with the patient in addition to re-inserting the needles?

Answer:

CPT coding for acupuncture is based on the time spent actively performing the procedure. This includes selecting the acupuncture points, inserting the needles, monitoring the patient’s response, and making any necessary adjustments. All these tasks require direct interaction with the patient throughout the treatment session. Essentially, the billing code reflects the dedicated time the practitioner spends actively treating the patient, not just the needle insertion itself.

Therefore, yes, the acupuncturist must be present for the entire procedure.

*This response is based on the best information available as of 3/13/25.

Interspace Between the Popliteal Artery and Capsule of the Posterior Knee (iPACK) Block

Question:

KZA, thank you for the information on the Coding Coach on the PENG block.  Do the same CPT codes apply to an interspace between the Popliteal Artery and Capsule of the posterior Knee (iPACK) block?

Answer:

While the Pericapsular Nerve Group (PENG) targets the anterior capsule of the hip, the iPACK block focuses on the posterior knee joint.

The creation of CPT codes 64466 – 64474 describes blocks performed in the fascial plane and distinguishes the fascial plane blocks from a nerve block.

CPT codes 64473 and 64474 are used for the infiltration of the interspace between the Popliteal Artery and the capsule (iPACK) block. The applicable code will depend on whether an injection or continuous infusion is performed.

• 64473 – Lower extremity fascial plane block, unilateral; by injection(s), including imaging guidance, when performed

• 64474 – Lower extremity fascial plane block, unilateral; by continuous infusion(s), including imaging guidance, when performed

*This response is based on the best information available as of 2/27/25.

Pericapsular Nerve Group (PENG) block

Question:

Prior to 2025 we had been instructed to code a Pericapsular Nerve Group (PENG) block to 64999?  What is the best CPT code for a PENG block in 2025?

Answer:

In this procedure, a local anesthetic is injected into the fascial plane located between the psoas tendon and the ilium. This targeted block affects the articular branches of the femoral, obturator, and accessory obturator nerves, which provide sensory innervation to the anterior capsule of the hip.

With the creation of the 2025 CPT codes:

• 64466 – Thoracic fascial plane block, unilateral; by injection(s), including imaging guidance, when performed

• 64467 – Thoracic fascial plane block, unilateral; by continuous infusion(s), including imaging guidance, when performed

• 64468 – Thoracic fascial plane block, bilateral; by injection(s), including imaging guidance, when performed

• 64469 – Thoracic fascial plane block, bilateral; by continuous infusion(s), including imaging guidance, when performed

• 64473 – Lower extremity fascial plane block, unilateral; by injection(s), including imaging guidance, when performed

• 64474 – Lower extremity fascial plane block, unilateral; by continuous infusion(s), including imaging guidance, when performed

CPT Codes 64473 and 64474 now represent the Pericapsular Nerve Group (PENG) block.  The code selection is based on whether an injection or continuous infusion is performed.

*This response is based on the best information available as of 2/13/25.