Background
Out of necessity, multiple continuous peripheral nerve blocks (CPNB) were administered in Operation Iraqi Freedom in 2003. Real-time imaging (portable ultrasound) and peripheral nerve stimulation have revolutionized the practice of CPNB anesthesia by providing objective evidence of needle proximity to targeted nerves. In the majority of peripheral nerve blocks, stimulation of nerves at a current of 0.5 mA or less suggests accurate needle placement for injection of local anesthetic. Differential blockade to achieve pain and temperature block while minimizing motor block can be achieved by using levorotatory enantiomers of local anesthetics and delivering specific concentrations to the nerve. A variety of anesthesia textbooks publish maximum recommended dosages for local anesthetics in an attempt to prevent high dose injections leading to toxicity. Because local anesthetic toxicity is related more to intravascular injection than to total dose, some physicians have suggested maximum dose recommendations are irrelevant. It is reasonable to assume that intravascular injections will occur, and practitioners of regional anesthesia should select techniques designed to minimize their occurrence.
This LCD addresses the use of these blocks in the definition and treatment of pain and conditions primarily treated with nerve blockade, such as complex regional pain syndrome and certain hyperhidroses. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is chronic when it has been present, continuously or intermittently, despite therapy for three months or more. CPNB involves the percutaneous insertion of a catheter directly adjacent to a peripheral nerve. The catheter is then infused with local anesthetic resulting in potent, site-specific analgesia that lasts well beyond the normal duration of a single injection nerve block. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency.
Prior to blockade, all patients with pain complaints require an evaluation that includes an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary comprehensive evaluation.
Indications
CPNB may be performed for several reasons and may be covered for the following purposes:
Therapeutic – to treat painful conditions or hyperhidroses that respond to nerve blocks
Prognostic – to predict the outcome of long-lasting interventions (e.g., neurolysis, rhizotomy).
Limitations
CPNB is a physician (or other qualified practitioner) service.
There is no coverage of CPNB services and supplies ‘incident to’ the professional services of a physician (or other qualified practitioner) in private practice.
CPNB should be performed with real-time ultrasound imaging and/or peripheral nerve stimulation to help prevent undesirable side effects such as muscle weakness.
In general, different types of nerve blocks should not be performed at the same setting as other blocks in the same body region.
Reimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic – regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain. When not used as the primary mode of anesthesia, the medically reasonable and necessary placement of CPNB may be reimbursable. Examples:
A continuous femoral nerve block placed to provide post-operative analgesia for an anterior cruciate ligament repair or a total knee replacement could be reported separately from the surgical anesthesia.
For shoulder surgery performed under continuous interscalene brachial plexus block along with a general anesthetic as the primary anesthesia, the block would be separately reportable as long as it will be used for post-op pain control.
A continuous brachial plexus block might also provide both the anesthesia and the postoperative pain control for an open reduction of a wrist fracture. Only the anesthesia code would be reported.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
99999 Not Applicable
CPT/HCPCS Codes
Group 1 Codes:
64416 N block cont infuse b plex
64446 N blk inj sciatic cont inf
64448 N block inj fem cont inf
64449 N block inj lumbar plexus
ICD-10 CODE DESCRIPTION
B02.1 – B02.29 – Opens in a new window Zoster meningitis – Other postherpetic nervous system involvement
B02.7 – B02.9 – Opens in a new window Disseminated zoster – Zoster without complications
E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy
E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy
E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy
E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
G50.0 Trigeminal neuralgia
G54.0 – G54.6 – Opens in a new window Brachial plexus disorders – Phantom limb syndrome with pain
G54.8 Other nerve root and plexus disorders
G55 – G59 – Opens in a new window Nerve root and plexus compressions in diseases classified elsewhere – Mononeuropathy in diseases classified elsewhere
G89.11 – G89.3 – Opens in a new window Acute pain due to trauma – Neoplasm related pain (acute) (chronic)
G90.50 – G90.59 – Opens in a new window Complex regional pain syndrome I, unspecified – Complex regional pain syndrome I of other specified site
I73.00 – I73.01 – Opens in a new window Raynaud’s syndrome without gangrene – Raynaud’s syndrome with gangrene
L74.510 – L74.519 – Opens in a new window Primary focal hyperhidrosis, axilla – Primary focal hyperhidrosis, unspecified
M25.511 – M25.519 – Opens in a new window Pain in right shoulder – Pain in unspecified shoulder
M25.551 – M25.569 – Opens in a new window Pain in right hip – Pain in unspecified knee
M46.1 Sacroiliitis, not elsewhere classified
M48.06 Spinal stenosis, lumbar region
M50.10 – M50.13 – Opens in a new window Cervical disc disorder with radiculopathy, unspecified cervical region – Cervical disc disorder with radiculopathy, cervicothoracic region
M51.14 – M51.17 – Opens in a new window Intervertebral disc disorders with radiculopathy, thoracic region – Intervertebral disc disorders with radiculopathy, lumbosacral region
M53.3 Sacrococcygeal disorders, not elsewhere classified
M53.81 – M53.83 – Opens in a new window Other specified dorsopathies, occipito-atlanto-axial region – Other specified dorsopathies, cervicothoracic region
M54.10 – M54.81 – Opens in a new window Radiculopathy, site unspecified – Occipital neuralgia
M79.2 Neuralgia and neuritis, unspecified
M94.0 Chondrocostal junction syndrome [Tietze]
M96.1 Postlaminectomy syndrome, not elsewhere classified
R07.1 Chest pain on breathing
R07.81 Pleurodynia
R10.10 Upper abdominal pain, unspecified
R10.2 – R10.30 – Opens in a new window Pelvic and perineal pain – Lower abdominal pain, unspecified
R25.0 – R25.9 – Opens in a new window Abnormal head movements – Unspecified abnormal involuntary movements
R52 Pain, unspecified
R68.84 Jaw pain
S14.2XXA – S14.9XXS – Opens in a new window Injury of nerve root of cervical spine, initial encounter – Injury of unspecified nerves of neck, sequela
S24.2XXA – S24.9XXS – Opens in a new window Injury of nerve root of thoracic spine, initial encounter – Injury of unspecified nerve of thorax, sequela
S34.21XA – S34.22XS – Opens in a new window Injury of nerve root of lumbar spine, initial encounter – Injury of nerve root of sacral spine, sequela
S34.4XXA – S34.9XXS – Opens in a new window Injury of lumbosacral plexus, initial encounter – Injury of unspecified nerves at abdomen, lower back and pelvis level, sequela
S44.00XA – S44.92XS – Opens in a new window Injury of ulnar nerve at upper arm level, unspecified arm, initial encounter – Injury of unspecified nerve at shoulder and upper arm level, left arm, sequela
S54.00XA – S54.92XS – Opens in a new window Injury of ulnar nerve at forearm level, unspecified arm, initial encounter – Injury of unspecified nerve at forearm level, left arm, sequela
S64.00XA – S64.92XS – Opens in a new window Injury of ulnar nerve at wrist and hand level of unspecified arm, initial encounter – Injury of unspecified nerve at wrist and hand level of left arm, sequela
S74.00XA – S74.92XS – Opens in a new window Injury of sciatic nerve at hip and thigh level, unspecified leg, initial encounter – Injury of unspecified nerve at hip and thigh level, left leg, sequela
S84.00XA – S84.92XS – Opens in a new window Injury of tibial nerve at lower leg level, unspecified leg, initial encounter – Injury of unspecified nerve at lower leg level, left leg, sequela
S94.00XA – S94.92XS – Opens in a new window Injury of lateral plantar nerve, unspecified leg, initial encounter – Injury of unspecified nerve at ankle and foot level, left leg, sequela
Z48.3 Aftercare following surgery for neoplasm
Z48.89 Encounter for other specified surgical aftercare
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