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Ganglion of Impar

K Posted Fri 30th of January, 2015 14:00:50 PM

What would be the best code to describe this procedure? Ganglion of Impar 64640...64999...64520...
The sacrococcygeal ligament was identified by palpation and confirmed by fluoroscopic. 3cc of 2% Lidocaine and 80mg of Depo-Medrol injected through the sacroccoccygeal ligament and then slightly anterior. 1cc of contrast material was used for fluoroscopic visualization to confirm sacral sympathetic chain spread.
Thank you

SuperCoder Answered Mon 02nd of February, 2015 08:17:42 AM

Thanks for your question.

If the physician performs a neurolytic (destructive) block, report CPT 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). Otherwise, report the unlisted-procedure code 64999 (Unlisted procedure, nervous system) at 12 units.

Pain physicians perform ganglion impar or ganglion of Walther blocks to treat sympathetically mediated pain of the perineum, rectum and genitalia. The pain is usually secondary to malignancy or a benign pain syndrome such as endometriosis, reflex sympathetic dystrophy or causalgia.

Hope it helps.

Thank you!

K Posted Mon 02nd of February, 2015 11:24:08 AM

Just to make sure I understand, I have two additional questions from your answer.

Depo Medrol is a corticosteroid drug and not a neurolytic agent so the code 64640 would not work...correct?

Per research on line (see info below) about the Ganglion of Impar, it says The ganglion Impar: part of the “sympathetic nervous system”...If that is correct, would you use an injction code 64520? Or does the description of lumbar or thoracic (paravertebral sympathetic) limit it to the lumbar and thoracic region and does not extend down to the sacral region?

The ganglion Impar is a group of nerves located just in front of the place where the sacrum and coccyx come together. The ganglion Impar is part of the “sympathetic nervous system.” The sympathetic nervous system is the part of the nervous system involved in the “fight or flight” response. Certain pain syndromes involve prolonged or extreme pain signals, perhaps related to increased irritability or excitability of the sympathetic nervous system. A classic example would be Complex Regional Pain Syndrome (CRPS, which was historically more commonly referred to as Reflex Sympathetic Dystrophy, or RSD). One of the classic and most dramatically helpful treatments for RSD, at least short-term, has been the injection of local anesthetic onto the sympathetic nerves that cover the body region were the patient is having the RSD pain. For example, a stellate ganglion block is done at the neck can help with RSD pain “downstream” in the arm or hand. Similarly, a lumbar (lower back) sympathetic block is done for RSD pain in the leg or foot. Thus, the sympathetic nervous system can be temporarily blocked with local anesthetic injections at the stellate ganglion (for upper limb pain syndromes), or at the lumbosacral sympathetic ganglions (for lower limb pain syndromes). Similarly, the sympathetic nervous system can also be temporarily blocked with local anesthetic injection at the ganglion Impar (particularly for coccyx pain syndromes).

SuperCoder Answered Mon 02nd of February, 2015 11:56:33 AM

Yes, it was an additional information for your use. 64640 would not be coded in this case.
Selecting an injection code could be tricky at times as type of nerves does not always lead us to a correct injection code. It depends upon the site of injection, technique used to inject, substance injected. The impar ganglion is not anatomically located in the thoracic or lumbar region, so there isn’t a valid CPT code for this block. You shouldn’t choose a “close or approximate” code. And AMA article specifically directs us to code it as unlisted.

CPT® Assistant.
September 2007; Volume 17: Issue 9

Coding Communication:Surgery: Nervous System

Question

What is the appropriate CPT code to report for a ganglion impar sympathetic block?

AMA Comment

Code 64999, Unlisted procedure, nervous system, should be reported. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, a procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure and the time, effort, and equipment necessary to provide the service.

Hope it further clarifies, if you have any question, please do let us know.

Thanks!

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