Injection procedures are one of the most common therapeutic interventions used to treat acute and chronic pain syndromes. A pain injection is an image-guided process that delivers medication through a precisely placed, small needle with the aim of providing pain relief and helping the patient return to normal activity. Proper physician documentation in the medical record is critical for pain management billing and coding to ensure timely, accurate payment.

Needle procedures address pain complaints by targeting tissues located in regions such as the spine, extremities, head and face, autonomic nervous system, and some internal organs. This blog discusses billing and coding for four needle procedures: epidural steroid injections (ESI), nerve blocks, acupuncture and Botox injections.

  • Epidural Steroid Injections (ESI): Epidural steroid injections are performed by physiatrists (PM&R), radiologists, anesthesiologists, neurologists, and surgeons. This minimally invasive procedure delivers medicines quickly into the epidural area to address neck, arm, back, and leg pain caused by inflamed spinal nerves due to various conditions such as spinal stenosis, herniated disc, degenerative disc, bone spurs, spondylolisthesis, or sciatica. Injected steroids reduce inflammation and relieve pain by opening up the narrowed passages. The goal of ESI is to reduce inflammation, relieve pain, improve function, and help patients easily begin or restart a physical therapy program. ESI can also help determine whether the patient could benefit from surgery for pain due to a herniated disc. Duration of pain relief may last for weeks or even years.

CPT codes for ESI:

  • 62320 Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance
  • 62321 Injection(s), of diagnostic or therapeutic substance(s)…, not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT)
  • 62322 Injection(s), of diagnostic or therapeutic substance(s)…, not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance
  • 62323 Injection(s), of diagnostic or therapeutic substance(s)…, not including neurolytic substances, including needle or catheter placement, interlaminarepidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT)
  • 64479 Injection(s), anesthetic agent and/or steroid, transforaminalepidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
  • 64480 Injection(s) …, transforaminalepidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure)
  • 64483 Injection(s)…,transforaminalepidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level
  • 64484 Injection(s)…, transforaminalepidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Billing: Fluoroscopy cannot be billed separately for epidural injection codes 62321 and 62323 and for transforaminal epidural codes 64479, 64480, 64483, and 64484.

  • Nerve Blocks: Another common pain management injection, nerve blocks are used to treat pain caused by inflamed nerves. This needle procedure involves injecting an anestheticclose to the affected nerve in order to block the pain signals. A nerve block injection can provide temporary pain relief for acute or chronic pain arising in the spine, neck, buttocks, legs, and arms. The injection can help damaged nerves heal over time. Diagnostic nerve blocks are used to identify the source of a patient’s pain. The effects of nerve blocks are immediate, but they usually provide only temporary pain relief.

Common CPT codes for billing nerve block injections:

  • 64405 Greater occipital nerve block
  • 64450 Lesser occipital nerve block
  • 64450 Other peripheral nerve
  • 64418 Suprascapular nerve
  • 64420 Intercostal nerve (single)
  • 64421 Intercostal nerve (multiple)
  • 64425 Ilioinguinal and Iliohypogastric nerve
  • 64400 Trigeminal nerve (any branch)
  • 64505 Sphenopalatine ganglion
  • 64510 Stellate ganglion (cervical sympathetic)
  • 64517 Superior hypogastric plexus
  • 64520 Thoracic or lumbar paravertebral sympathetic or ganglion impar block
  • 64530 Celiac plexus
  • 64455 Plantar common digital nerve (Morton’s neuroma):
  • 64999 Unlisted procedure

Billing:

  • A digital nerve block is bundled as part of the global surgical package and not separately coded when performed as a component of a surgical procedure. For e.g., when a nerve block for a laceration repair of a finger is performed, only the laceration repair should be coded and not the nerve block.
  • CPT code 64450 or CPT 64400 can be coded when performing associated dental nerve blocks
  • The procedure note should clearly indicate as to which nerve is being blocked.
  • Generally, ultrasound guidance used to perform a nerve block is a separately billable procedure
  • Check payer guidelines
  • Acupuncture: Acupuncture involves placing thin needles at specific points in the body to relieve pain by releasing endorphins – the body’s natural painkillers. Acupuncture has gained wider payer acceptance in recent times. Medicare started covering acupuncture as a treatment for chronic low back pain in 2020. CMS defines low back pain as:
    • Lasting 12 weeks or longer;
    • Nonspecific, in that it is has no identifiable system cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease
    • Is not associated with surgery; and
    • Is not associated with pregnancy.

The CPT codes for acupuncture are:

  • 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s)
  • 20561 Needle insertion(s) without injection(s); 3 or more muscles
  • 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
  • 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)
  • 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
  • 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal oneon-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)

Billing:

Medicare beneficiaries are covered for up to 12 acupuncture sessions in 90 days. An additional 8 sessions will be covered for patients showing an improvement. A maximum of 20 treatments are allowed annually. If the patient is not improving or is regressing, treatment should be discontinued.

For the purposes of a national coverage analysis (NCA) on the benefits of acupuncture for managing chronic low back pain, CMS defined acupuncture as “a process involving needles to be inserted into the skin (without an injection) at classical meridian points, extra points or Ah-shi points (painful points), accompanied by a definite feeling of ‘De Qi” (defined as “a sensation of numbness or distention sometimes generated by stimulating acupuncture needles by hand or with an electrical current”). Acupuncture is non-covered for all other indications.

  • Botox Injections: Injections of onabotulinumtoxinA (Botox®) have found acceptance as a pain management option for a wide variety of conditions such astennis elbow, chronic anal fissure, pain attributed to mastectomy and hemorrhoidectomy, headaches (including migraine), piriformis syndrome, facial pain, myofascial pain, temporomandibular joint syndrome (TMJ), low back pain, chronic prostatic pain, and whiplash (e.medicine.medscape.com).

The common injection codes to report Botox® injections and associated conditions are:

  • 64611 Chemodenervation of parotid and submandibular salivary glands, bilateral
  • 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)
  • 64615 muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)
  • 64616 neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)
  • 64642 Chemodenervation of one extremity; 1-4 muscle(s)
  • +64643 each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)
  • 64644 Chemodenervation of one extremity; 5 or more muscles
  • +64645 each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)
  • 64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s)
  • 64647 6 or more muscles
  • 64650 Chemodenervation of eccrine glands; both axillae

Billing:

  • Report J0585 Injection, onabotulinumtoxinA, 1 unit for each unit of Botox® injected (for 2 units of Botox®, report J0585 x 2 for the drug supply.
  • The number of units dispensed should be billed, not the number of vials.
  • Report an injection delivery code (supply code)
  • If used, report needle guidance during the Botox® injection
  • Report the appropriate ICD-10 code – this is crucial as payers do not reimburse Botox® for cosmetic purposes.

Providers of pain management medical coding services need to be knowledgeable about codes and coding conventions for these needle procedures to avoid problems like under-coding (lowered payments) or over-coding (audits). Further as payment policies can vary among payers, they will need to direct specific coding or payment related queries to the payer to ensure accurate billing of needle procedures. The physician’s documentation in the patient’s medical record should clearly establish medical necessity. This also can also present a challenge for pain management billing as determinations of medical necessity vary by from payer to payer.