Cindy Posted Thu 05th of December, 2019 07:02:55 AM
My provider dictate these notes for his procedure: Gave a series of injections in the left Suprascapular Nerve and anterior cervical nerve with 5% dextrose and 1% lidocaine. I coded this as 64418/LT. My physician insists that we should code 64418/LT and 64450. Can you help with this. Which way is the correct way to code this. I did not think the cervical nerve injection was a separate procedure. Thank you
SuperCoder Answered Fri 06th of December, 2019 07:37:09 AM
The suprascapular nerve arises from the upper trunk of the brachial plexus which is formed by the union of the ventral rami of the fifth and sixth cervical nerves, if the physician inject anesthetic agent in suprascapular nerve then there specific CPT code i.e. 64418. However, in given report physician has also given injection in anterior cervical nerve without further details and location of the nerve. Due to lack of documentation is it is difficult to suggest whether 64450 will be coded or not. If the root of the nerve is different than CPT 64450 will be coded. It is suggested please check body of operative report carefully and code accordingly.
Cindy Posted Fri 06th of December, 2019 07:50:35 AM
This is the body of the op notes, exactly what I have above, this is all I have. This is all that is in the op notes in the medical records. This was done in the office. Please advise your opinion on my original question.
SuperCoder Answered Mon 09th of December, 2019 08:27:16 AM
It cannot be billed without the clear documentation. So, it is suggested you should clarify with your physician at which level of anterior cervical nerve he had given the injection for proper code. The physician can add addendum in operative report to explain at which of level of anterior cervical nerve injection was given.
Hope this helps!
Cindy Posted Mon 09th of December, 2019 12:41:48 PM
If the provider does indicate which level of the anterior cervical nerve was injected then we could bill 64450? Is this correct
SuperCoder Answered Tue 10th of December, 2019 07:57:06 AM
If there is no specific CPT code for the injection procedure, then it will be coded with CPT 64450 for Injection of anesthetic agent in other peripheral nerve or branch.
Cindy Posted Tue 10th of December, 2019 07:59:59 AM
SuperCoder Answered Wed 11th of December, 2019 00:38:17 AM
Thank you, happy to help.