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Reporting 64405 for Third Occipital Nerve Blocks? Think Again

- Published on Tue, Jul 01, 2003
Physiatrists who administer third occipital nerve blocks should not automatically assume that 64405* (Injection, anesthetic agent; greater occipital nerve) is the most appropriate code. Most coding consultants recommend reporting 64470-22 instead of 64405 to more accurately describe these types of blocks.
Occipital Nerves Differ
When a physician indicates on the charge ticket that he or she performed an occipital nerve block, your instinct might tell you to assign 64405. But 64405 is not always the most accurate code, says Marvel Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver. Physiatrists administer injections to the third occipital nerve to help diagnose and treat different forms of headache and neck pain.
"The 'third occipital nerve' is not anatomically synonymous with the greater occipital nerve," Hammer says. "Physicians use both injections to diagnose and/or treat some forms of headache. But coding depends more on the anatomical structure and the procedure location than the patient's symptoms or diagnosis." 
The body contains three different sets of occipital nerves: the greater occipital, the lesser occipital, and the third occipital nerve (also referred to as the "least occipital nerve"). By reviewing the physiatrist's documentation, you can identify which nerve he or she blocked and assign the correct code for the procedure.
The greater occipital nerve originates from the dorsal ramus of the C2 spinal nerve. It has movement (motor) functions that innervate in the posterior neck muscles and sensory functions for the skin of the posterior surface of the scalp. Physicians often inject the greater occipital nerve to diagnose and treat occipital neuralgia (723.8, Other syndromes affecting cervical region). You should report 64405 for this procedure.
The lesser occipital nerve also originates from the C2 spinal nerve, but its source is the ventral ramus. It has only sensory functions that innervate the skin behind the ear. When blocking this nerve, you should report 64450* (Injection, anesthetic agent; other peripheral nerve or branch). 
The third occipital nerve (TON) is the superficial medial branch of the C3 spinal nerve's dorsal ramus. The TON, like the greater occipital nerve, has both motor and sensory functions. It innervates some of the neck muscles and the C2-3 facet joint. Pain stemming from this joint can be referred to the occiput and even as far as the frontal region and orbit.
Pinpoint the Correct Code
A physiatrist may inject all three occipital nerves to help diagnose or treat chronic headaches. The practitioner selects the appropriate occipital nerve injection based on the patient's medical history and condition (for example, a history of neck trauma such as whiplash [847.0, Sprains and [...]

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