Ganglion Impar Coding

[Painologist]

What code is everyone using for a Ganglion Impar injection these days? I was using 64999 but the last 2 I applied for got denied for being experimental by blue cross

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[SgtThunderfistMD]

64520, 77003

 

[callmeanesthesia]

If you are willing to take the lousy reimbursement you can just bill it as a medium joint injection and document sacrococcygeal joint injection, plus extra deposited anterior to the joint capsule.

 

[Painologist]

64520, 77003

I thought 64520 for lumbar sympathetic blocks? But I could see how it could also apply to ganglion impar...

 

[Agast]

I thought 64520 for lumbar sympathetic blocks? But I could see how it could also apply to ganglion impar...

Which part of the lumbar is the tailbone

If you are willing to take the lousy reimbursement you can just bill it as a medium joint injection and document sacrococcygeal joint injection, plus extra deposited anterior to the joint capsule.

I bill it as a small joint for that extra $7 😉

 

[Ducttape]

yes 64520 is lumbar sympathetic plexus block but ganglion impars = Ganglion of walther is part of the sympathetic chain.

 

[Painologist]

I'm leaning towards the 64520 vs cash pay for the injection. Hoping others chime in as well. I know another pain doc in the area that uses 64520 without issue.

 

[SSdoc33]

the true answer is 64999 + 77003 but it doesnt get paid.

i thnk very rarely a few insurers will reimburse for the 65420. it is controversial whether or not this is a true sympathetic block. if you are HOPD, bill the 64520 to pick up the RVUs, b/c there is a very good chance the billers will never catch on

 

[BoardingDoc]

Did one today. Billed 64999 and 77003.

Not sure why the above poster said it doesn't get paid (I'm not saying @SSdoc33 is wrong, I'm saying IDK what insurance is routinely rejecting for stuff like this)

 

[Agast]

Did one today. Billed 64999 and 77003.

Not sure why the above poster said it doesn't get paid (I'm not saying @SSdoc33 is wrong, I'm saying IDK what insurance is routinely rejecting for stuff like this)

You’re in fellowship right? The hospital billers routinely “fix” things after the fact so the procedures get paid

 

[BoardingDoc]

You’re in fellowship right? The hospital billers routinely “fix” things after the fact so the procedures get paid

That makes sense. I'll see if I can find out what it ultimately got billed as.

 

[Taus]

That makes sense. I'll see if I can find out what it ultimately got billed as.

If you would like to get paid for this procedure, I would suggest billing small joint 20600 (or medium), plus fluoro code 77003. I often stick on “other peripheral nerve” 64450 with a 59 modifier, but not sure if last part gets paid. I only do a handful of these per year, but getting paid for the above is better than a zero (or technically a loss with your overhead and opportunity cost for a spine injection slot) imo.

 

[lobelsteve]

Did one today. Billed 64999 and 77003.

Not sure why the above poster said it doesn't get paid (I'm not saying @SSdoc33 is wrong, I'm saying IDK what insurance is routinely rejecting for stuff like this)

Reimbursement for 64999 is typically $0

 

[bedrock]

If you would like to get paid for this procedure, I would suggest billing small joint 20600 (or medium), plus fluoro code 77003. I often stick on “other peripheral nerve” 64450 with a 59 modifier, but not sure if last part gets paid. I only do a handful of these per year, but getting paid for the above is better than a zero (or technically a loss with your overhead and opportunity cost for a spine injection slot) imo.

This is how I bill it. I get paid for all three codes typically

 

[BoardingDoc]

If you would like to get paid for this procedure, I would suggest billing small joint 20600 (or medium), plus fluoro code 77003. I often stick on “other peripheral nerve” 64450 with a 59 modifier, but not sure if last part gets paid. I only do a handful of these per year, but getting paid for the above is better than a zero (or technically a loss with your overhead and opportunity cost for a spine injection slot) imo.

Can you explain the use of a 59 modifier with 64450 in this case? Or when 59 is commonly used in pain in general? I'm reading about it and I see that you use it to decouple payments that are normally grouped together, though I'm not fully understanding when/why that's used.

From what I can see, 64450 doesn't seem to include any mention of imaging and thus pairing it with 77003 seems kosher, but I'm sure I'm missing something here.

 

[Painologist]

Well, I’m now doing 2 next week with 64520, no auth issues. Haven’t had one of these patients in a year, and then find 3 in a week (one paid cash after 64999 was denied as experimental). As far as I’m concerned, there should be a code for sacral sympathetic nerve blocks but there isn’t. Still a high risk procedure.

 

[Taus]

Well, I’m now doing 2 next week with 64520, no auth issues. Haven’t had one of these patients in a year, and then find 3 in a week (one paid cash after 64999 was denied as experimental). As far as I’m concerned, there should be a code for sacral sympathetic nerve blocks but there isn’t. Still a high risk procedure.

High risk of what? Rectal puncture if you go way too deep?

 

[Taus]

Can you explain the use of a 59 modifier with 64450 in this case? Or when 59 is commonly used in pain in general? I'm reading about it and I see that you use it to decouple payments that are normally grouped together, though I'm not fully understanding when/why that's used.

From what I can see, 64450 doesn't seem to include any mention of imaging and thus pairing it with 77003 seems kosher, but I'm sure I'm missing something here.

I don’t pretend to be an expert on this. My understanding is that it’s for a “separately identifiable procedure“, i.e., you are doing two different procedures. I learned this years ago when billing blocks and Rfa for sij. Billed the L5-S1 facet code and then 59 modifier for “peripheral nerve”, 3 units, for the lateral branches. That was until it got its own code… Which was subsequently killed off by the insurers, similar to genicular.

 

[SSdoc33]

I don’t pretend to be an expert on this. My understanding is that it’s for a “separately identifiable procedure“, i.e., you are doing two different procedures. I learned this years ago when billing blocks and Rfa for sij. Billed the L5-S1 facet code and then 59 modifier for “peripheral nerve”, 3 units, for the lateral branches. That was until it got its own code… Which was subsequently killed off by the insurers, similar to genicular.

Id like some clarification on this as well. i had only been using the -59 modifier when i am also billing an e/m. for example, if i am seeing a new patient and i do a GTB and gluteus medius tendon injection for example. i never thought about using it when i do 2 procedures at once (like say an SIJ and GTB) under flouro when i dont typically bill an e/m

 

[callmeanesthesia]

Id like some clarification on this as well. i had only been using the -59 modifier when i am also billing an e/m. for example, if i am seeing a new patient and i do a GTB and gluteus medius tendon injection for example. i never thought about using it when i do 2 procedures at once (like say an SIJ and GTB) under flouro when i dont typically bill an e/m

E&M plus procedure is a 25 modifier.

 

[SSdoc33]

E&M plus procedure is a 25 modifier.

what about e/m plus 2 procedures? with each being separately identifiable? that is 25 AND 59, correct?

 

[callmeanesthesia]

what about e/m plus 2 procedures? with each being separately identifiable? that is 25 AND 59, correct?

Yes. Although at that point the payor is probably going to find a way to screw you over. I know for us, Blue Cross won’t cover a 25 modifier if you’ve seen the patient for the same diagnosis in the last 90 days. So if the patient comes back to review imaging, and is also wanting a TPI done so that they can have something right away, Blue Cross is going to deny the 99214 for reviewing the imaging and ordering a procedure, and only pay for the TPI.

 

[Ducttape]

i would carefully consider using the modifier when doing 2 injections on medicare patients

most of the LCDs specifically state that only 1 injection is allowed at one time.



the safest use of the 25 modifier is when it is 2 distinct body parts. for example discussing and ordering cervical esi before performing lumbar facet intervention.

 

[Painologist]

High risk of what? Rectal puncture if you go way too deep?

Is puncturing the rectum not considered high risk? "way too deep" is a major overstatement in my opinion. Yes it is unlikely, but you're talking a matter of a a couple mm.

 

[Taus]

Is puncturing the rectum not considered high risk? "way too deep" is a major overstatement in my opinion. Yes it is unlikely, but you're talking a matter of a a couple mm.

Seems like a different ordinance of magnitude of risk compared to sticking the spinal cord on a CESI

 

[Dr. Ice]

Whoever wants my tailbone patients can have them. I pretty much stopped doing ganglion or coccygeal anything. I see them in consult and then send them to Patrick foye or give them the name of all the regional hospitals that have pain docs lol

 

[SSdoc33]

Whoever wants my tailbone patients can have them. I pretty much stopped doing ganglion or coccygeal anything. I see them in consult and then send them to Patrick foye or give them the name of all the regional hospitals that have pain docs lol

He still around? I remember he was into coccydynia 20 years ago. Called himself the tailbone guy or something like that.

Some patient love those impar blocks. Have several that come back 2x/year like clockwork

 

[Dr. Ice]

Tailbonedoctor.com

Ssdoc..too bad you don’t live by me..I could make you tailbone doc part deux