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Nerve Blocks for Acute Pain Management

Nerve Blocks for Acute Pain Management

CPT codes often take time to be established. Many new nerve blocks are still unlisted, even though they are now used quite commonly. Providers should not be discouraged from trying new techniques just because they may be unpayable. The process of establishing new codes may be slow, but it does eventually include valuable services.

The use of nerve blocks for acute pain management has undergone a dramatic transformation over the past ten years. Not only has the number of blocks performed by our clients increased significantly, especially for the management of orthopedic procedures, but providers have introduced new and refined techniques and approaches. Three main codes have generally served the needs of most providers. They are 64415 for interscalene blocks, 64447 for femoral nerve blocks and 64445 for sciatic block—all of which are paid from a surgical fee schedule and not ASA units, as would be the case for anesthesia services. There are a number of variations on the theme that have been sanctioned by CPT, the definitive coding reference guide. For example, adductor canal blocks are billed as femoral blocks and popliteal blocks are billed as sciatic blocks.

It used to be that there was no specific code for a TAP block, but then four codes were added three years ago reflecting the four ways TAP blocks can be performed: unilaterally or bilaterally; single shot or continuous (64486, 64487, 64488, and 64489). What is significant about these new codes is that ultrasonic guidance (USG) is bundled into the payment for each code, whereas USG is separately payable when used for the other blocks mentioned above.

As the volume of blocks continues to increase, our coding team is receiving details of blocks that are not sanctioned by CPT. The two most common are IPACK (infiltration between the popliteal artery and capsule of the knee) and erector spinae blocks. Since a CPT code is the key to payment for a surgical service, one must ask what happens when a provider performs an unlisted procedure? It is a critical question with an uncertain answer.

Controlling posterior knee pain after total knee arthroplasty is an important component of the comprehensive strategy for providing postoperative analgesia. This pain is mediated by articular branches that originate primarily from the tibial component of the sciatic nerve with contributions from the obturator nerve. Posterior knee pain can be controlled by a sciatic nerve block, but this leads to undesirable foot drop and may delay diagnosis and treatment of surgically induced common peroneal nerve injury. A selective tibial nerve block in the popliteal fossa is an alternative to the sciatic nerve block and can provide analgesia without causing a foot drop, but it decreases sensory perception in the sole of the foot and causes weakness of plantar flexion.

The articular branches, after arising from the main trunks of the tibial and obturator nerves, travel through a tissue space between the popliteal artery and the femur to innervate the posterior capsule of the knee. These articular branches can be blocked by infiltrating this tissue plane between the popliteal artery and the capsule of the knee (IPACK) with local anesthetic solution under ultrasound guidance. The goal of IPACK is to selectively block only the innervation of the posterior knee joint while sparing the main trunks of tibial and common peroneal nerves, thereby maintaining the sensorimotor function of the leg/foot. The IPACK technique was first introduced at the American Society of Regional Anesthesia (ASRA), Spring meeting in 2012.

Because these are not specifically popliteal blocks, they cannot be billed with 64445, and this is why CPT has designated them as unlisted for now. Our coding department posed a question to the American Medical Association (AMA)—the entity primarily responsible for developing CPT codes—as to whether an existing CPT code could be used for the IPACK block. The AMA responded as follows:

The IPACK block is directed at a tissue plane, not at a specific nerve. Currently, there is no specific CPT code to report an IPACK block. Therefore, code 64999, Unlisted procedure, nervous system, should be reported. It is important to avoid selecting a CPT code that merely approximates the service provided; therefore, if a specific code does not exist, always report the service using the appropriate unlisted procedure or service code. When reporting an unlisted code to describe a procedure or service, supporting documentation (eg, procedure report) should be submitted to provide an adequate description of the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the service.

Erector spinae plane (ESP) block is one of the newer interfascial techniques with potential applications. The ESP block is an interfascial block that can be performed by superficial or deep needle approach. In the superficial needle approach technique, the drug is injected between the rhomboid major muscle and the erector spinae muscle, whereas in the deep needle approach, the drug is injected below the erector spinae muscle. It has been recommended to use the deep needle approach as the drug is deposited closer to the costotransverse foramina and the origin of dorsal and ventral rami. It is supposed to work at the origin of spinal nerves, based on cadaveric and contrast studies.

When dye is injected into the interfascial plane deep into the erector spinae muscle bilaterally, craniocaudad spread of injectate from C7 to T8 on the right side and T1 to T8 on the left side will be noticed in the paraspinous gutter with lateral spread to the transverse processes at all levels. The injectate is also noticed slightly beyond the costotransverse junctions at levels T3 to T6 on the right and T4 to T8 on the left. Cadaveric studies have shown that a block at T5 level is sufficient to have unilateral multidermatomal sensory block, ranging from T1 to L3. This block serves the purpose of a paravertebral block without risk of pleural injury.

Our coding team also sent an inquiry to the AMA about this block and got the following response:

There is no specific CPT code that describes this service; therefore, code 64999, Unlisted procedure, nervous system, should be reported for the ESP block. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, 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.

The editors of the CPT code book must be convinced of the utility and value of a particular service or procedure before establishing a new code. It took a number of years before the new codes were established for TAP blocks. Many factors must be considered. We cannot know at this point if both of the blocks listed above will make it through this process. Some procedures may be quite popular at one point in time before they go out of favor. There was considerable interest in continuous catheter techniques for interscalene, femoral and sciatic blocks at a point in time, but most clients now prefer to just administer single-shot blocks. It is possible that one or both of these blocks will ultimately be superseded by yet another approach or technique. Only time will tell.

New clinical modalities must constantly be explored and refined. We certainly encourage our clients to try new techniques in order to test their effectiveness. We will do our very best to get them paid, but providers must understand that, when a procedure or service is unlisted, payment may be a challenge. Rest assured, though, that we will continue to report all new services so that the editors of CPT can and will consider adding new codes.

If you are currently performing IPACK or ESP blocks in your practice and would like an analysis on these blocks, please contact your account executive or email us at