Moderate Sedation Documentation

Question:

Is use of the nurse flow sheet when billing for moderate sedation with our pain injection procedures allowed?

Answer:

Per CPT coding guidelines, when billing for moderate sedation an independent trained observer is required.  An independent trained observer is an individual who is qualified to monitor the patient during the procedure, who has no other duties (e.g. assisting at surgery) during the procedure. 

Moderate sedation must be documented in the body of the procedure report; a separate flow sheet is not sufficient for the surgeon documentation.  Document “ I personally supervised Mary Brown RN providing 45 minutes of moderate sedation with XX mg Versed and XX mg Fentanyl”. 

*This response is based on the best information available as of 5/23/24.

Painful Spinal Hardware

Question:

Our physician injected 0.5% Marcaine and 80 mg of Depo-Medrol to existing spinal hardware (eg, pedicle screws) at L4, L5, and S1 bilaterally for a patient complaining of painful hardware. Can CPT code 64483 be reported? 

Answer:

No. CPT code 64483, (Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level), represents transforaminal epidural nerve root injection performed in the lumbar region. There is no specific CPT code for the injection of spinal hardware. CPT code 64999, Unlisted procedure, nervous system, would be most appropriate to describe the injections for pain performed outside the foramen, as indicated in the clinical scenario provided in this inquiry. Although three spinal level (L4, L5, S1 bilaterally) injections were performed, code 64999 should be reported only once to represent the multiple injections. 

*This response is based on the best information available as of 5/9/24.

Ganglion Impar Injection

Question:

What is the correct code to report when our physician performs a ganglion impar injection with Depo-Medrol and Lidocaine? 

Answer:

The most appropriate code for this procedure is unlisted. However, as with all pain injections, check your payor policies regarding specific coverage. 

*This response is based on the best information available as of 4/25/24.

Genicular Nerve Injection

Question:

What is the correct code (s) to report when the physician injects the superomedial and superolateral branches of the genicular nerve for knee pain with a steroid?

Answer:

The correct code to report for this service is 64454 (Injection (s), anesthetic agent (s) and/or steroid; genicular nerve branches including imaging guidance, when performed) with modifier 52 (Reduced Services). If all 3 nerve branches of the genicular nerve (superolateral, superomedial, and inferomedial) are not injected the service is reported with modifier 52. CPT code 64454 should not be used to report a piriformis injection. Piriformis muscle injection(s) should be reported using CPT code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

*This response is based on the best information available as of 4/11/24.

Piriformis Muscle Injection

Question:

We perform Piriformis muscle injections in the office under ultrasound guidance, what code should we be reporting for this service? 

Answer:

The correct code(s) that should be reported for the service are 20552 for the piriformis muscle injection and 76942 for the ultrasound guidance. 

Rationale: Per CPT Assistant April 2012  

There is a significant difference in the work and procedure, as well as intent, between an injection of the piriformis muscle and the perineural injection of the sciatic nerve. The sciatic nerve injection code (64445) should not be used to report a piriformis injection. Piriformis muscle injection(s) should be reported using CPT code 20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). 

*This response is based on the best information available as of 3/28/24.

Sphenopalatine Ganglion Block

Question:

How do I report a ganglion impar injection of Depo-Medrol and Lidocaine? 

Answer:

The most appropriate code for this procedure is unlisted. However, as with all pain injections, check your payor policies. Some policies consider a ganglion impar injection, specifically for rectal or pelvic pain, as not medically necessary. Others allow payment with an unlisted code. Using an existing code such as 64450, other peripheral nerve, without knowing the payor’s policy may get reimbursed inappropriately.

*This response is based on the best information available as of 3/14/24.