Nerve Blocks (Digital, Dental, Peripheral, etc.) FAQ

For payers following CPT guidelines, this service, code 64450 (Injection, anesthetic agent and/or steroid; other peripheral nerve or branch) or any other type of nerve block is not separately coded when performed as a component of a surgical procedure (e.g., laceration repair). In this instance, a digital nerve block is clearly bundled as part of the global surgical package, as outlined in the CPT Introduction to the Surgical section-CPT Surgical Package Definition. Under Medicare's global services package rules, Digital Nerve Blocks have long been bundled when performed as a component of a surgical procedure. For example, when performing a nerve block for a laceration repair of a finger, only the laceration repair should be coded and not the nerve block.

However, Digital Nerve Blocks performed as stand-alone procedures and not part of a surgical package (e.g., for pain control alone) generally remain separately billable under both Medicare and CPT coding principles.

Yes, a Dental Block is a billable procedure. CPT 64400 (Injection, anesthetic agent; trigeminal nerve, each branch (i.e., ophthalmic, maxillary, mandibular) can be coded when performing associated dental nerve blocks. This includes blocks for the infraorbital and inferior alveolar nerves.

The appropriate Evaluation/Management code modified with a -25 modifier may be used in addition to the nerve block code to identify a significant, “separately identifiable” medical service.

Multiple nerve blocks are available in CPT. These codes are dependent on the anatomical location of the nerve being blocked (CPT codes 64400-64530). It is important to be specific in your procedure note as to which nerve is being blocked. For example, when performing a Fascia Iliaca Block to anesthetize the femoral and lateral cutaneous nerve, use the CPT code 64447 [Injection, anesthetic agent (femoral nerve, single)].

Other nerve blocks commonly performed in the ED:

• Greater Occipital Nerve (CPT 64405)
• Intercostal Nerve – (CPT 64420, single level; CPT 64421, each additional level)
• Brachial Plexus – (CPT 64415, including image guidance)
  • Interscalane
  • Supraclavicular
  • RAPTIR (see example clinical scenario Q#5 below)
• TAP Block – Transversus abdominis plane (CPT 64488, including image guidance)
• Upper Extremity (CPT 64450)
  • Ulnar, Median, Radial Nerve
• Lower Extremity
  • Sciatic Nerve (CPT 64445, including image guidance)

At times, using ultrasound guidance to perform a nerve block is also a separately billable procedure. CPT code 76942 [Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) imaging supervision and interpretation] could be coded, as well as the specific nerve block code.  For additional information, see the ACEP Ultrasound FAQ set.

The Retroclavicular Approach to the Infraclavicular Region (RAPTIR) is a single-injection brachial plexus nerve block that may be used for pain control when performing closed reduction of distal radius fractures or similar procedures. See ACEP Now for a more detailed explanation of a RAPTIR block.

The CPT surgical package includes “Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia”; however, a RAPTIR is a regional block as opposed to the included local block and is separately reportable.

An ED visit that included a RAPTIR block would be coded with the appropriate 9928x E/M code if a separately identifiable service was performed. The CPT code for the procedure (e.g., 25605-54 - Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation), and the CPT code for the injection (64415 - Injection, anesthetic agent; brachial plexus, single).

Trigger Point Injections are a billable service but seem to be closely scrutinized by payers. While there is no CMS policy at the national level (NCD) regarding trigger point injections, several CMS Medicare contractors have LCDs (Local Carrier Determination) that restrict payment for trigger point injections to specific ICD-10-CM codes. See the LCD from the CMS website for the list of codes that support medical necessity (a short list) and the list of codes that do not support medical necessity (much longer list).  

Commercial payers may be reluctant to cover Trigger Point Injections as the first choice for pain management, except in cases where joint movement is impaired, the muscle cannot be fully stretched or is locked in a fixed position. 

The best practice is to include documentation that indicates conservative/noninvasive treatment, e.g., oral pain medication, heat/cold treatment, massage therapy, etc., has been tried and failed.

There are two CPT codes for Trigger point injections:

• 20552-Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
• 20553-Injection(s); single or multiple trigger point(s), 3 or more muscles
  • Do not report 20552, 20553 in conjunction with 20560, 20561 (needle insertion(s) without injection), 1 or 2 muscles; 3 or more muscles) for the same muscle(s)
  • Modifier 50- bilateral should not be reported with 20552 or 20553

The codes are based on the number of muscles injected, regardless of how many injections are given. Only one code should be reported per treatment, since either code covers multiple injections.

When utilized, ultrasound guidance can be reported in addition to the injection using CPT Code:

• 76942-Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Procedure documentation should include the site of the injection, how many injections were given, and the number of muscles injected.