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CPT® Code 64420

Official Description

Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level

Common Language Description

The procedure described by CPT® Code 64420 involves the injection of anesthetic agents and/or steroids into a single intercostal nerve, which is a type of nerve block. This intervention can serve both diagnostic and therapeutic purposes. The intercostal nerves are classified as mixed nerves, meaning they carry both sensory and motor fibers. They are responsible for innervating the skin and muscles of the upper extremities, thorax, and abdominal wall. These nerves emerge from the spinal cord and exit the posterior aspect of the intercostal membrane, located just distal to the intervertebral foramen. Following their exit, the intercostal nerves travel into the intercostal groove, which runs parallel to the ribs, and branches of these nerves can be found situated between the ribs. Typically, intercostal nerve blocks are performed at specific anatomical locations, most commonly along the posterior axillary line or just lateral to the paraspinal muscles at the angle of the rib. Prior to the injection, the healthcare provider identifies and marks the planned injection site(s) along the inferior border of the rib(s). The procedure involves the careful introduction of a needle beneath the inferior border of the rib, advancing it until it reaches the subcostal groove. Once the needle is correctly positioned, the anesthetic agent and/or steroid is injected to achieve the desired effect. For coding purposes, CPT® Code 64420 is utilized for the injection of a single intercostal nerve, while CPT® Code 64421 is designated for each additional intercostal nerve level that is injected.

1. Indications

The injection of anesthetic agents and/or steroids into the intercostal nerve is indicated for various conditions that may cause pain or discomfort in the thoracic region. The following are explicitly provided indications for this procedure:

Chronic Pain Management of chronic pain conditions affecting the thoracic wall or upper abdomen.
Post-Surgical Pain Relief of pain following thoracic or abdominal surgeries.
Neuropathic Pain Treatment of neuropathic pain syndromes involving the intercostal nerves.
Rib Fractures Alleviation of pain associated with rib fractures or other thoracic injuries.

2. Procedure

The procedure for injecting anesthetic agents and/or steroids into a single intercostal nerve involves several key steps, which are detailed as follows:

Step 1: Patient Preparation The patient is positioned comfortably to allow access to the thoracic region. The area of injection is cleaned and sterilized to minimize the risk of infection.
Step 2: Identification of Injection Site The healthcare provider identifies the appropriate intercostal nerve level for injection, typically along the inferior border of the rib. The site is marked to ensure accuracy during the procedure.
Step 3: Needle Insertion A needle is introduced beneath the inferior border of the rib at the marked site. Care is taken to avoid injury to surrounding structures.
Step 4: Needle Advancement The needle is advanced until it reaches the subcostal groove, where the intercostal nerve is located. This step is crucial for ensuring that the anesthetic agent or steroid is delivered effectively.
Step 5: Injection of Anesthetic Agent/Steroid Once the needle is in the correct position, the anesthetic agent and/or steroid is injected. The volume and type of medication used may vary based on the clinical scenario and provider preference.

3. Post-Procedure

After the injection, the patient is monitored for any immediate adverse reactions or complications. It is common for patients to experience temporary relief from pain, although the full effect of the injection may take some time to manifest. Patients may be advised to avoid strenuous activities for a short period following the procedure to allow for optimal healing. Follow-up appointments may be scheduled to assess the effectiveness of the injection and determine if additional treatments are necessary.

Short Descr	NJX AA&/STRD NTRCOST NRV 1
Medium Descr	INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL
Long Descr	Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level
Status Code	Active Code
Global Days	000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Procedure or Service, Multiple Reduction Applies
ASC Payment Indicator	Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P6C - Minor procedures - other (Medicare fee schedule)
MUE	1
CCS Clinical Classification	8 - Other non-OR or closed therapeutic nervous system procedures

This is a primary code that can be used with these additional add-on codes.

64421	Add-on Code MPFS Status: Active Code APC T ASC A2 CPT Assistant Article Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (List separately in addition to code for primary procedure)
77002	CPT Add On MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)

50	Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
LT	Left side (used to identify procedures performed on the left side of the body)
RT	Right side (used to identify procedures performed on the right side of the body)
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
GC	This service has been performed in part by a resident under the direction of a teaching physician
X4	Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
X5	Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XP	Separate practitioner, a service that is distinct because it was performed by a different practitioner
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure
76	Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
CR	Catastrophe/disaster related
22	Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
26	Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
53	Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
58	Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
62	Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
74	Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80	Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
AG	Primary physician
AQ	Physician providing a service in an unlisted health professional shortage area (hpsa)
AS	Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GA	Waiver of liability statement issued as required by payer policy, individual case
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
GW	Service not related to the hospice patient's terminal condition
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GZ	Item or service expected to be denied as not reasonable and necessary
KX	Requirements specified in the medical policy have been met
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SG	Ambulatory surgical center (asc) facility service
T3	Left foot, fourth digit
T7	Right foot, third digit
T9	Right foot, fifth digit
X2	Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter