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.

TAP Block?

Question:

I am new to coding pain management procedures. Please explain what a TAP procedure is and why it is typically performed. I am unfamiliar with this procedure and what CPT code to use.

Answer:

Thank you for your inquiry. A Transverse Abdominis Plane (TAP) block is a regional anesthesia technique used to manage abdominal pain. The physician injects a local anesthetic into the plane between the internal oblique and the transversus abdominis muscles during the procedure. The anesthetic blocks the nerves that supply sensation to the anterior abdominal wall, providing pain relief for the patient.

TAP blocks are commonly used for diagnostic purposes, such as differentiating between abdominal wall pain and visceral pain, postoperative pain management after abdominal surgeries, hernia repairs, and appendectomies, or to treat chronic pain syndromes such as chronic abdominal wall pain.

Several CPT codes are available for this procedure, and the use of one will depend upon the documentation in the operative note and whether the procedure is performed unilaterally or bilaterally or by injection or continuous infusion. The CPT codes include imaging guidance when performed, so there is no additional reporting.

TAP blocks reported by injection (s)

64486: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)

64488: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)

TAP blocks reported by continuous infusions (catheter placement is included)

64487: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by continuous infusion(s) (includes imaging guidance, when performed)

64489: Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by continuous infusions (includes imaging guidance, when performed)

*This response is based on the best information available as of 1/30/25.

Prescription Drug Management

Question:

Every patient I see is in pain, and I discuss prescription medications (primarily prescription NSAIDs, Neurontin, and/or muscle relaxers) with almost every patient. If I document “discussed prescription drug management with Mobic, patient defers and will continue Motrin OTC as needed.” Is this prescription drug management?

Answer:

If this is a true clinical management option for this unique patient based on their history, pain level, the number of times you have seen them, imaging, and the patient is not responding to OTC meds, and you determine Mobic is the best next course of treatment for the patient, and they still decline it, this can support prescription drug management. You are still recommending something that has a risk to the patient. This is from the clinical standpoint, which must be clearly documented in the note.

Be aware, many payors have increased scrutiny in this area and may not see it the same way. It can go both ways, so you must be careful. If you routinely do this for every patient to increase your code level and submit all of these as level fours, you may be at risk and set yourself up for an audit from a payor.

Prescription drug management involves a prescription-strength drug that the patient must go to the pharmacy to get. The name, dosage, strength of the drug, and how to take it, along with any rationale for why it is prescribed at the time of the visit, also need to be documented. Payors want to see this documentation in the plan of care. Prescription drug management involves the risk that you take prescribing and the risk to the patient taking the medication.

Refilling a current prescription does not automatically equate to a Moderate level of MDM. The billing practitioner must document the rationale for continuing the medication for the patient at the visit (e.g., the patient’s pain is well-controlled on x mg at this time, and he/she will continue the current dose).

*This response is based on the best information available as of 1/16/25.

History and Examination requirement for E/M services

Question:

I have been practicing for many years and am confused about the E/M guidelines since the changes were made a few years ago, mainly for my office services 99202-99215.  My coder says I should document an history and examination, but I don’t think this is required anymore.  Am I correct?

Answer:

The evaluation and management service levels are no longer determined by history and examination but are based on medical-decision making or Time except for emergency department visit codes (99281-99285), which do not contain a time component. However, a clinically relevant history and examination are required based on the practitioner’s clinical judgment. It is essential to tell the “story” of the patient’s clinical picture in the documentation. The history and examination support the medical necessity for the visit and provide a more complete representation of the patient’s condition for continuity and coordination of care with other clinical practitioners.

*This response is based on the best information available as of 1/2/25.

Counting the Number and Complexity of Problems Addressed

Question:

Would cervical and lumbar radiculopathy count as one or two problems, and are they considered acute, chronic, stable, or not stable on the table of risk?

Answer:

Good questions! First, the number of problems would be two since these are different body parts, and each will require its own diagnosis and treatment recommendation.

The next is issue is, are the presenting problems acute or chronic, and that will require a good history of present illness, detailing how the problem presented. Was it an injury? Is it degenerative, so by the very nature of degenerative disease it is chronic. An accurate selection of where the problems “fit’ within the problem element cannot be determined without a good history.

*This response is based on the best information available as of 12/19/24.