Intercostal nerve block technique

[knoxdoc]

I was told a study was done showing that an intercostal nerve block performed by simply advancing the needle to the posterior aspect of the rib and injecting there was just as effective as injecting below the rib. Is there any truth to these outlandish claims? Anyone have the reference? Thanks.

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[DOctorJay]

do it with ultrasound so you can see (and avoid) the pleura

 

[nvrsumr]

Used to do these blind all the time. Now that I use US I am certain I caused many asymmtomatic PTX

 

[silvester78]

I have done a couple of intercostal blocks, using ultrasound.
I' ll never do it blind again!!

 

[Jcm800]

i still like fluoro...

 

[nvrsumr]

I did em with fluoro too. Im not in love with US for everything but for superficial structures like ICN blocks it is so easy and the image is anatomic not just fuzz.... It really doesnt take more time.

 

[mid|ine]

I'm sure if you inject enough it will track down and block the nerve.

Under flouro with significant caudal angulation, I use a bent tip, land on the inferior aspect of the rip, rotate until I slip off, advancing a couple of mm, aspirate, and inject.

 

[lobelsteve]

Under fluoro, start in between rib spaces/ Advance while withdrawing on plunger and when air aspirates, pull back 2mm. Then inject 4cc bupi and a tiny bit of gum. Not big red, it is too spicy for the pleura.

 

[Ducttape]

Under fluoro, start in between rib spaces/ Advance while withdrawing on plunger and when air aspirates, pull back 2mm. Then inject 4cc bupi and a tiny bit of gum. Not big red, it is too spicy for the pleura.

well, the patient is usually too busy screaming to chew his own gum.

try this instead - inject meds, then a little bit of crazy glue. work fast, so the glue doesnt seal up the bore of the needle.

you get to keep the gum for yourself.😀

 

[PinchandBurn]

I was told a study was done showing that an intercostal nerve block performed by simply advancing the needle to the posterior aspect of the rib and injecting there was just as effective as injecting below the rib. Is there any truth to these outlandish claims? Anyone have the reference? Thanks.

I think this works. Likely safer as well.

In terms of fluro vs ultrasound. I think fluro is much faster for this...especially if based on palpation you know for the most part where you are going and are using fluro for confirmation.

 

[clubdeac]

How do you guys bill for ICNBs? I think the code says something about multiple nerves. Can you bill multiple nerves or does just one code cover all additional levels? And what's the reimbursement difference between fluoro and US for these?

 

[Ducttape]

How do you guys bill for ICNBs? I think the code says something about multiple nerves. Can you bill multiple nerves or does just one code cover all additional levels? And what's the reimbursement difference between fluoro and US for these?

if my billers are correct, 64420 is for a single level, and 64421 is for intercostal nerve, multiple, regional block.

 

[clubdeac]

if my billers are correct, 64420 is for a single level, and 64421 is for intercostal nerve, multiple, regional block.

So when you do 3-4 blocks do you just bill 64420x3 or 64421?

 

[joshmir]

Can you see the nerve with ultrasound?

 

[Ducttape]

So when you do 3-4 blocks do you just bill 64420x3 or 64421?

when i do more than 1 block, it is always 64421.

You dont visualize the nerve per se, because it is usually in the groove behind the lateral margin of the rib, but you do visualize the muscle plane that the nerve and vessels reside in. you want the needle hopefully to get to the interior intercostal muscle.

The beauty of ultrasound is that you can see that you are in that layer, and you can see where the pleura is, and dont advance the needle into the pleura itself.... hopefully...

 

[lobelsteve]

Can you see the nerve with ultrasound?

I've started using US for chemistry.

I can see quarks.

 

[clubdeac]

when i do more than 1 block, it is always 64421.

You dont visualize the nerve per se, because it is usually in the groove behind the lateral margin of the rib, but you do visualize the muscle plane that the nerve and vessels reside in. you want the needle hopefully to get to the interior intercostal muscle.

The beauty of ultrasound is that you can see that you are in that layer, and you can see where the pleura is, and dont advance the needle into the pleura itself.... hopefully...

Ok so I'm terarded. For 3 intercostal nerves, is it correct to bill 64421 x 3 or just 64221 once?

 

[nvrsumr]

Ok so I'm terarded. For 3 intercostal nerves, is it correct to bill 64421 x 3 or just 64221 once?

x 1.

 

[lobelsteve]

64420 single nerve.
64421 anything more than a single nerve.

You cannot bill 64420 x anything but once.

 

[clubdeac]

So you get paid the same whether you do 2, 3 or 4 ICNBs. That's crap! And I assume it works the same for tpi's. There's a code for 1-2 muscles and another for 3-4 muscles. I assume you can just use each code once and get paid the same whether you do 3, 4 or 5 tpi's in one setting. Arghhh