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01/13/2005    Name Withheld by Moderator

CPT 64640

Query: CPT 64640


Can someone verify the correct code for 4%
alcohol infiltration for destruction of
neuromas?


It was my understanding that the most accurate
code was CPT 64640 (destruction by neurolytic
agent; other peripheral nerve or branch).


Recently, I was at a coding seminar sponsored by
New Jersey Podiatric Medical Society, and the
speaker, Gail Rounds, the Medicare
representative, gave a brief discussion about 3
CPT codes that were the focus of audit probes in
2004. She noted that in one of the findings of
Medicare (Empire New Jersey) CPT 64640 was being
used inappropriately because 1) it was reported
as being billed for what appeared to be more a
*destruction* of an isolated *nerve lesion* than
an actual peripheral nerve or nerve branch, and
2) the concentration of the solution used (4%
alcohol) was not generally considered to be
neurolytic.


She did not go into clinical detail, or mention
whether this determination was the medical
director's opinion or pain specialist
consultants, but the fact that it was, and may
still very well be, a focus of CPT 64640 for
audits by our Medicare carrier leaves me with
concern.


Is CPT 64640 the right code to bill when
injecting a Morton's neuroma or any other
neuroma with a 4% alcohol solution? Is 4%
alcohol typically the concentration of solution
injected by pain specialists to effectively
destroy a peripheral nerve or nerve branch?


Name Withheld by Moderator


Codingline Response: The following description
of CPT 64640 is from the Coding Companion from
Ingenix:


"This procedure is performed to treat chronic
pain. The affected nerve is destroyed using
chemical, thermal, electrical or radiofrequency
techniques. These techniques may be used singly
or in combination. These procedures are designed
to destroy the specific site in the nerve root
that produce the pain while leaving sensation
intact. Generally intravenous conscious sedation
is utilized during the initial phase of the
procedure so that the patient can assist the
physician in identifying the site of pain and
the correct placement of the neurolytic agent.
Local anesthesia is administered during the
destruction phase of the procedure. Using
separately reportable fluoroscopic guidance, a
needle is inserted into the affected nerve root.
An electrode is then inserted through the needle
and a mild electrical current is passed through
the electrode. The current produces a tingling
sensation at a site on the nerve. The electrode
is manipulated until hte tingling sensation is
felt at the same site responsible for the pain,
a local anesthetic is administered and a
neurolytic agent applied. Chemical destruction
involves injection of a neurolytic substance
(e.g., alcohol, phenol, glycerol) into the
affected nerve root..."


The key here, to me, is that this destruction of
nerve by neurolytic agent injection is into the
nerve ROOT, not a lesion. Neither the Coding
Companion nor CPT specifies the concentration of
the alcohol. so that would be left to standard
of treatment. I think the procedure is not being
fulfilled based on this description.


But, I will preface (or suffix) all this with
the caveat that I am not a clinician.


Barbara Cobuzzi, MBA, CPC
Brick, NJ


Other messages in this thread:


10/26/2005    Name Withheld by Editor

Audited for CPT 64640

Query: Audited for CPT 64640


I billed inter-metatarsal neuromas and neuritis
with procedure code CPT 64640 with 4%
ethanol/Marcaine solution and was audited by
Medicare for services billed from 01/01/2000
thorugh 12/31/2003. Of 58 medical records
randomly selected for review 10 of them were
forwarded to a podiatric consultant to review
the accuracy of my billing. The consultant found
that my use of CPT code 64640 was inconsistent
with the standard of care used by most
podiatrists.


The consultant stated that the coder’s desk
reference 2004 from Ingenix describes the
procedure CPT code 64640, to treat chronic
pain. “The affected nerve is destroyed using
chemical, thermal, electrical, or radio
frequency techniques. These procedures are
designed to destroy the specific site in the
nerve root that produce the pain, while leaving
sensation intact. Generally intravenous
conscious sedation is utilized during the
initial phase of the procedure so that the
patient can assist the physician in identifying
the site of pain and correct placement of the
neurolytic agent. Local anesthesia is
administered during the destruction phase of the
procedure. Using separately reportable
fluoroscopic guidance, a needle is inserted in
to the affected nerve root.”


This described procedure indicates destruction
of the nerve by neurolytic agent injection into
the nerve root, not the 4% alcohol injections as
billed.


Does any podiatrist perform neurolytic
injections according to these new published
guidelines? What defense can I present to
justify my billing?


Name Withheld by Editor


02/02/2005    Annette Mazzanti

CPT 64640 Injection Denial

Query: CPT 64640 Injection Denial


A patient was seen in our office for pain 3rd
interspace right foot. An ultrasound confirmed
the presence of a neuroma. In the office, the
patient was given sclerosing nerve injections
(CPT 64640) to the interspace at intervals of
every 10 days for a series of 6 injections.


The insurance company denied the claims
stating "surgery performed in the office" is not
a covered benefit. I have appealed to the
insurance company stating this is an injection
that was given in the office, and not an open,
cutting procedure. Any suggestions would be
helpful.


Annette Mazzanti, Insurance Coordinator
Office of Ronald Miller, DPM
Van Nuys, CA


Codingline Response: On the issue of the payer
denying your office "procedure", CPT is divided
into sections: E/M, Surgery, Pathology and
Laboratory, Medicine, etc. The injection you are
referring to "resides" under "Surgery" (along
with cutting toenails and applying a cast). So,
if this patient's insurance plan benefit
structure language excludes ALL in-office
surgery [coding] from reimbursement, then the
insurance company's denial of your claim is
correct, and you may only be left with charging
the patient.


Mark Schilansky, DPM
Catskill, NY


03/31/2004    Gene Mirkin, DPM

Trailblazer Medicare Rejection of CPT 64640

Query: Trailblazer Medicare Rejection of CPT
64640


I understand that the local medical review
policy (LMRP) for Trailblazer Medicare is
reconsidering the coverage appropriateness of
CPT 64640 for injection of Morton's neuromas.
What is the general consensus as to what to do
with the claims that have been recently rejected
for performing this procedure?


Gene Mirkin, DPM
Kensington, MD


Codingline Response: Unless Trailblazer Medicare
has indicated to you (and others), in writing,
that they will be including ICD-9 355.6
(Morton's neuroma) to the list of CPT 64640-
approved diagnosis codes, and that they would
retroactively process any claims previously
submitted and denied, you have very little in
the way of options. Of course, if, prior to
administering the sclerosing injection, you had
your patients sign an advance beneficiary notice
(ABN) and include a "GA" modifier with CPT
64640, then you can bill your usual and
customary fee directly to the patient who would
be responsible. If you failed to obtain an ABN
prior to injection, you cannot bill the patient
for CPT 64640.


Codingline Expert: Harry Goldsmith, DPM


03/12/2004    Arnold S. Beresh, DPM

Trailblazer Medicare & CPT 64640

Query: Trailblazer Medicare & CPT 64640


Trailblazer Medicare (Texas, Virginia, Maryland,
Washington, DC, Delaware, Indian Health
Services), in its local medical review policy
(effective date December 29, 2003)
on "Paravertebral Facet Joint Denervation", has
not included ICD-9 355.6 (neuroma) as an
approved ICD-9 code for CPT 64640 (destruction
by neurolytic agent; other peripheral nerve or
branch). Without this indication, we will see
(and already have seen) denials when billing
Trailblazer CPT 64640.


Are any other Medicare and non-Medicare payers
denying payment on CPT 64640 for sclerosing of
Morton's neuromas?


Arnold S. Beresh, DPM
Hampton, VA


Codingline Responses: Blue Cross and Blue Shield
of Michigan is not denying payment for CPT 64640
(destruction by neurolytic agent; other
peripheral nerve or branch), but has issued a
policy whereby the service is only paid once.


The explanation was the service destroyed the
nerve, and, therefore, subsequent nerve
destructions were not needed.


Craig Gastwirth, DPM
Detroit, MI


As the Texas Trailblazer CAC rep, I have been
hard at work on this for several months.. I was
told that the code was inadvertently put into a
local medical review policy (LMRP) dealing with
paravertebral facet joint denervation.
Unfortunately, once in, it is taking some doing
to get it out of the policy.


I had been told that the change to remove the
code from the LMRP would occur several weeks
ago. That arbitrary deadline given to me by the
carrier medical director has come and gone. Be
assured that I will continue to keep this topic
in front of the Medicare personnel here in
Dallas, and hope to be able to report a change
shortly.


In the mean time, there is no other coding that
I can recommend to take the place of CPT 64640.
If you are performing the destruction of a
peripheral nerve, have your Medicare patient
sign an advance beneficiary notice (ABN), and
add a "-GA" to the CPT 64640 code. That way,
when the claim is denied, you can seek payment
from your patient. I would not expect that if
and when the code is "opened" for destruction of
Morton's neuroma that change will be made
retroactive to the date of the paravertebral
facet joint denervation LMRP.


Paul Kinberg, DPM
Dallas, TX

Sorbothane