Nerve Blockade: Somatic, Selective Nerve Root, and Epidural Noridian Administrative Services, LLC

Please note: This is a Draft policy. Proposed/Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed/Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor. Contractor Information

Contractor Name

Noridian Administrative Services, LLC

Contract Number

03102

Contract Type

MAC - Part B

Associated Contract Numbers

(MAC (MAC (MAC (MAC (MAC (MAC (MAC (MAC (MAC

-

Part Part Part Part Part Part Part Part Part

B B B B B B B B B

-

03202) 03302) 03502) 03602) 03402) 02202) 02102) 02402) 02302)

Noridian Noridian Noridian Noridian Noridian Noridian Noridian Noridian Noridian

Administrative Administrative Administrative Administrative Administrative Administrative Administrative Administrative Administrative

Services, Services, Services, Services, Services, Services, Services, Services, Services,

LLC, LLC, LLC, LLC, LLC, LLC, LLC, LLC, LLC

Proposed/Draft LCD Information

Source LCD ID

N/A

1

Contractor Information Proposed LCD ID

DL33188

Proposed LCD Version Number

4

Proposed LCD Title

Nerve Blockade: Somatic, Selective Nerve Root, and Epidural

AMA CPT / ADA CDT Copyright Statement

CPT only copyright 2002-2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright (c) American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) section allows coverage and payment for only those services that are considered to be reasonable and necessary. Title XVIII of the Social Security Act; Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim. Title XVIII of the Social Security Act, Section 1862(a)(7) is excludes routine physicals (except screening examinations allowed by statute). IOM 100-3 (1) 30.3.1 and 30.3.2 and PIM 7.2.8.4: Acupuncture is a non-covered service. IOM 100-4 (23) 20.9: Anesthesia is included in surgical procedures.

Jurisdiction

AZ

Coverage Guidance Coverage Indications, Limitations and/or Medical Necessity

Note: Providers should seek information related to National Coverage Determinations (NCD) and other Centers for Medicare & Medicaid Services (CMS) instructions in CMS Manuals. This LCD only pertains to the contractor's discretionary coverage related to this service.

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Contractor Information This LCD solely addresses the use of these blocks in the definition and treatment of pain and conditions primarily treated with nerve blockade, such as complex regional pain syndrome and certain hyperhidroses. For the purposes of this LCD and consistent with standard community understanding and the recommendations of specialty societies, pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. PAIN is chronic when it has been present, continuously or intermittently, despite therapy for three months or more. 1 An appropriate injection of local anesthetic induces a temporary interruption in the conduction of impulses by peripheral nerves or nerve trunks. Longer-lasting or permanent blockade may be induced with the injection of neurolytic agents and/or application of thermal (not pulsed) radiofrequency. Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary or other collaborative comprehensive evaluation. Nerve blocks may be performed for several reasons and may be covered for the following purposes: • Diagnostic - to determine the source of pain e.g., to identify or pinpoint a nerve that acts as a pathway for pain; to determine the type of nerve that conducts the pain; to distinguish between pain that is central (within the spinal cord) or peripheral (outside the spinal cord) in origin; or to determine whether a neurolytic block or surgical lysis of the nerve should be performed. The type of diagnostic test may include injecting saline to stimulate pain or injecting an anesthetic agent to evaluate the patient's response, as an initial diagnostic step so that other pain relief options may be considered. • Therapeutic - to treat painful conditions that respond to nerve blocks (e.g., celiac block for pain of pancreatic cancer) and /or “inappropriate” sympathetic nervous system activity. Note: Epidural steroids should be used only in the presence of radiculopathy. • Prognostic - to predict the outcome of long-lasting interventions

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Contractor Information (e.g., infusions, neurolysis, rhizotomy). In general, different types of nerve block should not be performed at the same setting as other blocks in the same body region. However, in patients with pain problems that involve more than one area of the body, a somatic nerve block may be provided on the same day as another type of block, such as, an epidural block, selective nerve root block, bilateral sacroiliac joint injection, etc. In this situation, the body areas blocked must be discrete from each other and separated by physical distance, e.g. a lumbar paravertebral somatic nerve block and a cervical facet block. In most cases, treatment of pain requires less than and no more than three of the same type of injection (or sets of injections) to alleviate pain. If a previous series of epidural injections provided significant relief of pain as evidenced by objective criteria and the pain reoccurs, a repeat series of epidural injections-not to exceed three in a series may be performed. Additional treatment will be denied as not reasonable and necessary unless significant improvement is documented with subjective evidence, such as, return to work, decrease in other forms of analgesia, etc. See “Documentation Requirements” below. Reimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic-regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain. Following discharge from the post-anesthesia care unit (PACU), the medically reasonable and necessary placement of regional or peripheral pain blocks or initiation of other new pain interventions or “top-up” dosing may be reimbursable. Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control. SOMATIC NERVE BLOCK This nerve blockade is commonly accomplished through injections of local anesthetic in the near proximity of the nerve. The exact technique varies both with anatomy and clinical objective. Indications Diagnostically, the block may be used to delineate uncertain pain generators (for example, sympathetic vs. somatic). Therapeutically, the block may be used to achieve relief from the acute pain associated with trauma, acute herpetic and other types of neuralgias, and chronic cancer-related pain. Blockade of multiple somatic nerves (at different levels) may be necessary for proper evaluation and/or management of acute and chronic pain in

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Contractor Information any given patient. When blockade has been of value in the relief of acute or cancer pain, somatic blockade may be maintained through the infusion of local anesthetics via indwelling catheter. Fluoroscopy and ultrasound may be necessary to the performance of this type of block. Limitations Radiculopathy and other neurological deficit that may require further evaluation and management should be ruled out or established by physical/electrophysiologic/other examinations prior to performing the blocks and evaluated. SELECTIVE NERVE ROOT BLOCK Selective nerve root block (SNRB) is primarily a diagnostic procedure, in which a selective, reproducible blockade of a specific nerve root(s) is achieved with the injection of a local anesthetic with or without steroid. Any nerve root from C-2 to S-5 can be selectively blocked. Fluoroscopic or CT imaging should be used to facilitate the proper placement of the tip of the injecting needle adjacent to the lateral margin of the neuroforamen. Radiologic guidance should include the use of dye, when not contraindicated, to ascertain that the infusion of the medication does not appear to reach the epidural space. Nerve stimulation and paresthesia can be used as additional confirmation AND/ or if dye is contraindicated. Definitive diagnosis cannot be made solely based upon the outcome of this block, but this block can be used to confirm the findings of a carefully conducted evaluation, including history, physical, and careful neurologic testing. Indications The SNRB may be useful in the diagnosis of presumed acute radicular pain, of less than three months duration, in which surgical intervention is planned and the SNRB is to confirm the results of careful history, physical and neurological testing. The SNRB may also be useful in differential diagnosis: in establishing the type of pain (somatic, visceral or functional) and source(s) or foci. Clinical scenarios include but are not limited to the following. 1. The patient's pain appears to be due to classic monoradiculopathy but the neuro-diagnostic studies fail to provide a structural explanation (i.e., selective nerve root blockade helps establish or rule out the diagnosis of radiculopathy).

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Contractor Information 2. The patient has a classic monoradicular pain and the radiological studies demonstrate an abnormality only related to another nerve root. 3. The clinical picture is suggestive but not typical for both nerve root and distal nerve or joint disease and SNRB may determine the etiology. Selective nerve root blockade may be used as a therapeutic procedure for the treatment of pain due to Complex Regional Pain Syndrome (CRPS), radicular pain secondary to post-surgical scarring and monoradicular pain for which no surgically correctable lesion can be found. In these cases, it is standard procedure is to limit the number of blocks to three or less in any given treatment period unless a documented and reasonable expectation of progressive and significant improvement with an additional block(s) exists. If there is reason to suspect that the treatment of pain may require more than three blocks, for example, the pain of herpes zoster or cancer, more definitive pain control techniques, including, infusions, should be considered. Therapeutic blockade with local anesthetic may be combined with depository steroids to produce longer-lasting relief. EPIDURAL BLOCK There are several routes of epidural injection: interlaminar, transforaminal, and caudal. Epidural blocks may be performed with or without insertion of a directional catheter to target specific pathology. The site of pathology should be considered when choosing the route and level of injection. Fluoroscopy and contrast may document the adequacy and appropriateness of the site and spread of the medication. Indications Epidural injections of local anesthetics are indicated in the treatment of diseases listed under covered ICD-9-CM codes. Epidural injections should be applied with a frequency appropriate to their value. In most cases these discrete injections should not be repeated in less than five days, should be limited to a total of three injections in a three to six month period of time and should only be repeated if the injections produced significant and sustained relief documented by objective evidence, such as improvements in the ability to perform ADL’s. When steroids are used, consideration should be given to the potential complications of STEROIDS and ESPECIALLY repetitive steroid dosing. Steroids should be used only in the presences

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Contractor Information of radiculopathy. Proposed/Draft Process Information Associated Information

The medical record must be made available to Medicare upon request. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits in addition to guidance in this LCD. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Whichever guidance is more restrictive should be adhered to. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act. When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and any pertinent peer-reviewed literature that supports the request. At a minimum, literature such as two (2) Phase II studies (human studies of efficacy, pivotal) or one (1) Phase III study (evidence of safety and efficacy, pivotal) must be submitted for the Medical Director’s review. This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies. The Section titled "Does the ‘CPT 30% Rule' apply?" needs clarification. This rule comes from the AMA (American Medical Association), the organization that holds the copyrights for all CPT codes. The rule states that if, in a given section (e.g., surgery) or subsection (e.g., surgery, integumentary) of the CPT Manual, more than 30% of the codes are listed in the LCD, then the short descriptors must be used rather than the long descriptors found in the CPT Manual. This policy is subject to the reasonable and necessary guidelines and the limitation of liability provision. This medical policy consolidates and replaces all previous policies and publications on this subject by NAS and its predecessors for Medicare Part B.

Sources of

1

Merskey H, Bogduk N. Description of chronic pain syndromes and

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Contractor Information Information and Basis for Decision

definitions of pain terms. In: Classification of Chronic Pain, 2nd ed. Seattle, WA: IASP press; 1994. Satterthwaite, Dollison. Handbook of Pain Management, 2nd Edition, 1994, Williams and Wilkins. Karmakar MK et al. Thoracic paravertebral block for management of pain associated with multiple fractured ribs in patients with concomitant lumbar spinal trauma. Reg Anesth Pain Med 2001; 26:169-173 Lang SA. The use of a nerve stimulator for thoracic paravertebral block (letter). Anesth 2002; 97:521. Naja MZ et al. Nerve-stimulator guided paravertebral blockade vs. general anesthesia for breast surgery. Euro J. Anaesth. 2003;20:897-903. Raj P.P. Peripheral neurolysis in the management of pain. In Waldman, Winnie ed. Interventional Pain Management. 1996, WB Saunders, Phil, PA. pp. 395-400. Klein SM et al. Thoracic paravertebral block for breast surgery. Anesth and Analg. 2000;90:1402-5. Boezaart A et al. Paravertebral approach to the brachial plexus: an anatomic improvement in technique. Reg Anesth Pain Med. 2003;28:241-4. Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95:771-80. Kelly FE et al. Continuous paravertebral block for thoracoabdominal oesophageal surgery (letter). Anaesth. 2005; 60:98. Karmakar MK. Thoracic paravertebral block. Anesthesiology 2001; 95:771-80. NAS Intermediary Advisory Committee (IAC) on Pain ASA Pain Committee Yale University School of Medicine, Department of Pain Management. Connecticut Society of Anesthesiology Local Medical Review Policy from Nationwide Insurance Company. Medicare Operations Spine Five: 193-200, 1980.

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Contractor Information Journal of Neurosurgery 43:448-451, 1975. Joint section on pain, the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Carrier Advisory Committee (CAC) Meetings

Meeting Date 03/26/2013

Meeting Information Advisory Committee Meeting Notes This medical policy will be presented at the Medicare Part B Open Public Meeting March 26, 2013. It will again be discussed at the following Carrier Advisory Committee meetings on the following dates: Alaska 05/09/2013 Arizona 05/28/2013 Idaho 05/22/2013 Montana 05/09/2013 North Dakota 05/14/2013 Oregon 04/13/2013 South Dakota 05/16/2013 Utah 05/02/2013 Washington 04/09/2013 Wyoming 05/02/2013

Comment Period Start Date

03/26/2013

Comment Period End Date

07/11/2013

Released to Final LCD Date

Not yet released.

Reason for Proposed LCD

Creation of Uniform LCDs Within a MAC Jurisdiction

Proposed LCD Contact

Noridian Administrative Services LLC Contractor Medical Director(s) Policy Development - Medicare Part B - Drafts 900 42nd Street S. Fargo, ND 58108 [email protected]

Coding Information

9

Contractor Information

Bill Type Codes

012x

Hospital Inpatient (Medicare Part B only)

013x

Hospital Outpatient

022x

Skilled Nursing - Inpatient (Medicare Part B only)

023x

Skilled Nursing - Outpatient

085x

Critical Access Hospital

Revenue Codes

CPT/HCPCS Codes

045X

Emergency Room - General Classification

051X

Clinic - General Classification

052X

Free-Standing Clinic - General Classification

076X

Specialty Services - General Classification

096X

Professional Fees - General Classification

Group 1: Paragraph FOR SOMATIC NERVE BLOCK: Group 1: Codes 64400

N block inj trigeminal

64402

N block inj facial

64405

N block inj occipital

64408

N block inj vagus

64410

N block inj phrenic

64412

N block inj spinal accessor

64413

N block inj cervical plexus

64415

N block inj brachial plexus

64416

N block cont infuse b plex

64417

N block inj axillary

64418

N block inj suprascapular

64420

N block inj intercost sng

10

Contractor Information 64421

N block inj intercost mlt

64425

N block inj ilio-ing/hypogi

64430

N block inj pudendal

64435

N block inj paracervical

64445

N block inj sciatic sng

64446

N blk inj sciatic cont inf

64447

N block inj fem single

64448

N block inj fem cont inf

64449

N block inj lumbar plexus

64450

N block other peripheral

64455

N block inj plantar digit

64505

N block spenopalatine gangl

64508

N block carotid sinus s/p

64510

N block stellate ganglion

64517

N block inj hypogas plxs

64520

N block lumbar/thoracic

64530

N block inj celiac pelus

64620

Injection treatment of nerve

64632

N block inj common digit

64640

Injection treatment of nerve

Group 2: Paragraph FOR SELECTIVE NERVE ROOT BLOCK (SNRB): Do not report 77003 in conjunction with 64479, 64483, or 64484. Group 2: Codes 62281

Treat spinal cord lesion

62282

Treat spinal canal lesion

64479

Inj foramen epidural c/t

64483

Inj foramen epidural l/s

64484

Inj foramen epidural add-on

Group 3: Paragraph

11

Contractor Information FOR EPIDURAL BLOCK: Group 3: Codes 62281

Treat spinal cord lesion

62282

Treat spinal canal lesion

62310

Inject spine cerv/thoracic

62311

Inject spine lumbar/sacral

62318

Inject spine w/cath crv/thrc

62319

Inject spine w/cath lmb/scrl

Group 4: Paragraph FOR IMAGING GUIDANCE: Group 4: Codes 77003

Does the CPT 30% Coding Rule Apply? ICD-9 Codes that Support Medical Necessity

Fluoroguide for spine inject

Yes

Group 1: Paragraph Group 1: Codes 053.0

HERPES ZOSTER WITH MENINGITIS

053.10

HERPES ZOSTER WITH UNSPECIFIED NERVOUS SYSTEM COMPLICATION

053.11

GENICULATE HERPES ZOSTER

053.12

POSTHERPETIC TRIGEMINAL NEURALGIA

053.13

POSTHERPETIC POLYNEUROPATHY

053.14

HERPES ZOSTER MYELITIS

053.8

HERPES ZOSTER WITH UNSPECIFIED COMPLICATION

053.9

HERPES ZOSTER WITHOUT COMPLICATION

337.20

REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED

337.21

REFLEX SYMPATHETIC DYSTROPHY OF THE UPPER LIMB

337.22

REFLEX SYMPATHETIC DYSTROPHY OF THE LOWER

12

Contractor Information LIMB 337.29

REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE

338.11*

ACUTE PAIN DUE TO TRAUMA

338.12*

ACUTE POST-THORACOTOMY PAIN

338.18*

OTHER ACUTE POSTOPERATIVE PAIN

338.19*

OTHER ACUTE PAIN

338.21

CHRONIC PAIN DUE TO TRAUMA

338.22

CHRONIC POST-THORACOTOMY PAIN

338.28

OTHER CHRONIC POSTOPERATIVE PAIN

338.29

OTHER CHRONIC PAIN

338.3

NEOPLASM RELATED PAIN (ACUTE) (CHRONIC)

350.1

TRIGEMINAL NEURALGIA

353.0

BRACHIAL PLEXUS LESIONS

353.1

LUMBOSACRAL PLEXUS LESIONS

353.2

CERVICAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.3

THORACIC ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.4

LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.5

NEURALGIC AMYOTROPHY

353.6

PHANTOM LIMB (SYNDROME)

353.8

OTHER NERVE ROOT AND PLEXUS DISORDERS

354.0

CARPAL TUNNEL SYNDROME

354.1

OTHER LESION OF MEDIAN NERVE

354.2

LESION OF ULNAR NERVE

354.3

LESION OF RADIAL NERVE

354.4

CAUSALGIA OF UPPER LIMB

354.5

MONONEURITIS MULTIPLEX

354.8

OTHER MONONEURITIS OF UPPER LIMB

354.9

MONONEURITIS OF UPPER LIMB UNSPECIFIED

13

Contractor Information 355.0

LESION OF SCIATIC NERVE

355.1

MERALGIA PARESTHETICA

355.2

OTHER LESION OF FEMORAL NERVE

355.3

LESION OF LATERAL POPLITEAL NERVE

355.4

LESION OF MEDIAL POPLITEAL NERVE

355.5

TARSAL TUNNEL SYNDROME

355.6

LESION OF PLANTAR NERVE

355.71

CAUSALGIA OF LOWER LIMB

355.79

OTHER MONONEURITIS OF LOWER LIMB

355.8

MONONEURITIS OF LOWER LIMB UNSPECIFIED

355.9

MONONEURITIS OF UNSPECIFIED SITE

443.0

RAYNAUD'S SYNDROME

705.21

PRIMARY FOCAL HYPERHIDROSIS

719.41

PAIN IN JOINT INVOLVING SHOULDER REGION

719.45

PAIN IN JOINT INVOLVING PELVIC REGION AND THIGH

719.46

PAIN IN JOINT INVOLVING LOWER LEG

720.2

SACROILIITIS NOT ELSEWHERE CLASSIFIED

722.80

POSTLAMINECTOMY SYNDROME OF UNSPECIFIED REGION

722.81

POSTLAMINECTOMY SYNDROME OF CERVICAL REGION

722.82

POSTLAMINECTOMY SYNDROME OF THORACIC REGION

722.83

POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

723.1

CERVICALGIA

723.4

BRACHIAL NEURITIS OR RADICULITIS NOS

723.8

OTHER SYNDROMES AFFECTING CERVICAL REGION

724.03

SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

724.1

PAIN IN THORACIC SPINE

14

Contractor Information 724.2

LUMBAGO

724.3

SCIATICA

724.4

THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

724.79

OTHER DISORDERS OF COCCYX

729.2

NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED

733.6

TIETZE'S DISEASE

780.1

HALLUCINATIONS

781.0

ABNORMAL INVOLUNTARY MOVEMENTS

784.92

JAW PAIN

786.50*

UNSPECIFIED CHEST PAIN

786.52

PAINFUL RESPIRATION

789.09

ABDOMINAL PAIN OTHER SPECIFIED SITE

953.0

INJURY TO CERVICAL NERVE ROOT

953.1

INJURY TO DORSAL NERVE ROOT

953.2

INJURY TO LUMBAR NERVE ROOT

953.3

INJURY TO SACRAL NERVE ROOT

953.4

INJURY TO BRACHIAL PLEXUS

953.5

INJURY TO LUMBOSACRAL PLEXUS

953.8

INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

953.9

INJURY TO UNSPECIFIED SITE OF NERVE ROOTS AND SPINAL PLEXUS

954.0

INJURY TO CERVICAL SYMPATHETIC NERVE EXCLUDING SHOULDER AND PELVIC GIRDLES

954.1

INJURY TO OTHER SYMPATHETIC NERVE EXCLUDING SHOULDER AND PELVIC GIRDLES

954.8

INJURY TO OTHER SPECIFIED NERVE(S) OF TRUNK EXCLUDING SHOULDER AND PELVIC GIRDLES

954.9

INJURY TO UNSPECIFIED NERVE OF TRUNK EXCLUDING SHOULDER AND PELVIC GIRDLES

955.0

INJURY TO AXILLARY NERVE

15

Contractor Information 955.1

INJURY TO MEDIAN NERVE

955.2

INJURY TO ULNAR NERVE

955.3

INJURY TO RADIAL NERVE

955.4

INJURY TO MUSCULOCUTANEOUS NERVE

955.5

INJURY TO CUTANEOUS SENSORY NERVE UPPER LIMB

955.6

INJURY TO DIGITAL NERVE UPPER LIMB

955.7

INJURY TO OTHER SPECIFIED NERVE(S) OF SHOULDER GIRDLE AND UPPER LIMB

955.8

INJURY TO MULTIPLE NERVES OF SHOULDER GIRDLE AND UPPER LIMB

955.9

INJURY TO UNSPECIFIED NERVE OF SHOULDER GIRDLE AND UPPER LIMB

956.0

INJURY TO SCIATIC NERVE

956.1

INJURY TO FEMORAL NERVE

956.2

INJURY TO POSTERIOR TIBIAL NERVE

956.3

INJURY TO PERONEAL NERVE

956.4

INJURY TO CUTANEOUS SENSORY NERVE LOWER LIMB

956.5

INJURY TO OTHER SPECIFIED NERVE(S) OF PELVIC GIRDLE AND LOWER LIMB

956.8

INJURY TO MULTIPLE NERVES OF PELVIC GIRDLE AND LOWER LIMB

956.9

INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB

957.0

INJURY TO SUPERFICIAL NERVES OF HEAD AND NECK

957.1

INJURY TO OTHER SPECIFIED NERVE(S)

957.8

INJURY TO MULTIPLE NERVES IN SEVERAL PARTS

957.9

INJURY TO NERVES UNSPECIFIED SITE

V58.42

AFTERCARE FOLLOWING SURGERY FOR NEOPLASM

V58.43

AFTERCARE FOLLOWING SURGERY FOR INJURY AND TRAUMA

V58.49

OTHER SPECIFIED AFTERCARE FOLLOWING

16

Contractor Information SURGERY Group 1: Asterisk *Reimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic-regardless of the method by which the care provider, including the anesthesiologist, decides to manage the pain. Following discharge from the postanesthesia care unit (PACU), the medically reasonable and necessary placement of regional or peripheral pain blocks or initiation of other new pain interventions or “top-up” dosing may be reimbursable. Providers should not expect separate payment for the establishment of epidural or other pain blocks unless the block is placed following discharge from PACU due to documented inadequate pain control. *ICD-9-CM code 786.50 is to be used to describe rib pain.

ICD-9 Codes that DO NOT Support Medical Necessity

All ICD-9-CM codes not listed in this policy under "ICD-9-CM Codes that Support Medical Necessity" above.

Associated Documents Attachments

There are no attachments for this LCD

Related Local Coverage Documents

This LCD version has no Related Local Coverage Documents.

Related National Coverage Documents

This LCD version has no Related National Coverage Documents.

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