Neurosurgery Coding: Pin Down Headache Dx Choice with These Tips

Published: 30th March 2011
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Does your neurosurgery practice provide greater occipital nerve blocks? If so, don't let your neurosurgery coding turn into a headache. Confirm specifics about the patient's headache and the service your provider offered to pinpoint the proper diagnosis and procedure codes every time.

Where do you find the occipital nerve?

The greater occipital nerve originates from the posterior medial branch of the C2 spinal nerve and provides sensory innervations to the posterior area of the scalp extending right up to the top of the head. Doctors normally inject the greater occipital nerve at the level of the superior nuchal line just above the base of the skull for occipital headaches or neck pain.

Medical coding tip: Few physician practices include a small illustration in the chart that the physician can mark with various injection sites. Including this type of tool helps your physician clearly document the injection location, which helps you select the proper nerve injection code and submit more exact claims.

What's the patient's headache type?

Your doctor's documentation might include notes ranging from 'occipital headache' to 'occipital neuralgia to 'cervicogenic headache'. Your job is to see to it that you interpret the notes and assign the most proper diagnosis.

Occipital headache: ICD-9's alphabetic index doesn't include a specific listing for occipital headache. Owing to this, use the general code 784.0 (Headache), which includes "Pain in head NOS." Further details in your provider's notes might lead to diagnoses such as 339.00 (Cluster headaches), 307.81 (Tension headache), 339.1x (Tension type headache), or 346. xx (Migraine).

Occipital neuralgia: When your provider documents occipital neuralgia, you have a more specific diagnosis to code. Greater occipital neuralgia produces a burning, aching, or throbbing pain or a tingling or numbness along the back of the head. You will code diagnosis 723.8 (Other syndromes affecting cervical region).

Cervicogenic headache: The alphabetic index does not include a listing directing medical coders to assess a specific ICD-9 code. In the absence of a better option, many coders report 784.0 (Headache).

The provider carried out which service?

Doctors can opt to treat occipital nerve pain by administering a nerve block or eventually by ablating the nerve.

Nerve block: Administering a nerve block for the time being relieves the patient's pain. For a greater occipital nerve block, go for 64405 (Injection, anesthetic agent; greater occipital nerve). Some insurance companies categorize 64405 as experimental or investigational; therefore these might deny coverage. You should review coverage policies so you know what to expect when filing your claim.

Nerve destruction: When more conventional treatments is unable to provide long term pain relief, the physician might choose to go for nerve destruction. Whether you see the term radiofrequency ablation or "thermocoagulation" on the patient's chart, you have two code choices depending on where the doctor carried out the destruction. If he carried out RF destruction at the terminal end of the nerve, go for 64640. And if he carried out RF at the origination, submit 64626. However confirm that your provider destroyed the nerve instead of treating it with pulses. The pulsed treatment does not appear to destroy the nerve, which eliminates 64640 and 64626. Instead, pulsed treatment falls under 64999.

How do you deal with bilateral injections?

When your provider administers bilateral GON injections, confirm the patient's insurance company prior to completing your claim.

Why: Most Medicare contractors want you to report bilateral procedures as a single line item with a single unit of service and modifier 50 (bilateral procedure) added. But then private payers often need two lines for bilateral claims:

  • Line 1 with the procedure code, modifier RT, & one unit of service

  • Line 2 with the procedure code, modifier LT, & one unit of service.

    Know well that Medicare reimburses bilateral procedures at 150 percent of the allowed amount. This means you will get 100 percent reimbursement for the first injection and 50 percent reimbursement for the second one.

    For more on this and for other specialty specific articles to assist your neurosurgery coding, sign up for a good medical coding resource like Coding Institute.

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