Friday, 24 February 2017

64455 (anesthetic and steroid) and 64632 (neurolytic agent)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

This policy addresses the injection of chemical substances, such as local anesthetics, steroids, sclerosing agents and/or neurolytic agents into ganglion cysts, tendon sheaths, tendon origins/insertions, ligaments, costochondral areas, or near nerves of the feet (e.g., Morton's neuroma) to affect therapy for a pathological condition.

Note: the term "Morton's neuroma" is used in this policy generically to refer to a swollen inflamed nerve in the ball of the foot, including the more specific conditions of Morton's neuroma (lesion within the third intermetatarsal space), Heuter's neuroma (first intermetatarsal space), Hauser's neuroma (second intermetatarsal space) and Iselin's neuroma (fourth intermetatarsal space). This policy applies to each.

Injection of a carpal tunnel is indicated for the patient with a mild case of the carpal tunnel syndrome if oral non-steroidal anti-inflammatory drugs (NSAIDs) and orthoses have failed or are contraindicated. 

Though there are many similarities between Morton’s neuroma and carpal tunnel syndrome, CPT 2009 contains 64455 (anesthetic and/or steroid) and 64632 (neurolytic agent), the specific codes for the Morton‘s neuroma injections. Providers are reminded to use the appropriate one of these codes instead of the previously instructed use of 28899. 

Injection into tendon sheaths, ligaments, tendon origins or insertions, ganglion cysts, or neuromas may be indicated to relieve pain or dysfunction resulting from inflammation or other pathological changes. 

Proper use of this modality with local anesthetics and/or steroids should be short-term, as part of an overall management plan including diagnostic evaluation, in order to clearly identify and properly treat the primary cause. In some circumstances after diagnosis has been confirmed, injection of a sclerosing or neurolytic agent may be appropriate for longer-term management.

The signs or symptoms that justify these treatments should be resolved after one to three injections (see reference 2 below, under "Sources of Information and Basis for Decision"). 

Injections beyond three must be justified by the clinical record indicating a logical reason for failure of the prior therapy and why further treatment can reasonably be expected to succeed. A recurrence may justify a second course of therapy.

Injection therapies for Morton's neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. 

These therapies are not to be coded using 20550, 20551, 64450, 64640 or other assigned CPT codes. Rather, the provider of these therapies must bill with CPT code 64455 or 64632 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's neuroma). 

The provider must not bill CPT codes 64450 or 64640 for these injections, since those codes respectively address the additional work of an injection of an anesthetic agent (nerve block), neurolytic or sclerosing agent into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas such as a carpal tunnel or Morton's neuroma.

Injections for plantar fasciitis are addressed by 20550 and ICD-10-CM M72.2. Injections for calcaneal spurs are addressed as are other tendon origin/insertions by 20551. Injections to include both the plantar fascia and the area around a calcaneal spur are to be reported using a single 20551.

Medical necessity for injections of more than two sites at one session or for frequent or repeated injections is questionable. Such injections are likely to result in a request for medical records which must evidence careful justification of necessity.

"Dry needling" of ganglion cysts, ligaments, neuromas, tendon sheaths and their origins/insertions are non-covered procedures. 

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review. 

Expand/collapse the Coding Information section Coding Information Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. 

Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. 

Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.


Group 1 Paragraph: N/A

Group 1 Codes:







ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: Note: Diagnosis codes are based on the current ICD-10-CM codes that are effective at the time of LCD publication. Any updates to ICD-10-CM codes will be reviewed by Noridian; and coverage should not be presumed until the results of such review have been published/posted.

These are the only covered ICD-10-CM codes that support medical necessity:

Group 1 Codes:

Show entries for Group 1 ICD-10 Codes that Support Medical Necessity: 

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Group 1Codes


G56.01* Carpal tunnel syndrome, right upper limb
G56.02* Carpal tunnel syndrome, left upper limb
G56.03* Carpal tunnel syndrome, bilateral upper limbs
G57.53* Tarsal tunnel syndrome, bilateral lower limbs
G57.61* Lesion of plantar nerve, right lower limb
G57.62* Lesion of plantar nerve, left lower limb
G57.63* Lesion of plantar nerve, bilateral lower limbs
M24.211 Disorder of ligament, right shoulder
M24.212 Disorder of ligament, left shoulder
M24.221 Disorder of ligament, right elbow
M24.222 Disorder of ligament, left elbow
M24.231 Disorder of ligament, right wrist
M24.232 Disorder of ligament, left wrist
M24.241 Disorder of ligament, right hand
M24.242 Disorder of ligament, left hand
M24.251 Disorder of ligament, right hip
M24.252 Disorder of ligament, left hip
M24.271 Disorder of ligament, right ankle
M24.272 Disorder of ligament, left ankle
M24.274 Disorder of ligament, right foot
M24.275 Disorder of ligament, left foot
M24.28 Disorder of ligament, vertebrae
M25.711 Osteophyte, right shoulder
M25.712 Osteophyte, left shoulder
M25.721 Osteophyte, right elbow
M25.722 Osteophyte, left elbow
M25.731 Osteophyte, right wrist
M25.732 Osteophyte, left wrist
M25.741 Osteophyte, right hand
M25.742 Osteophyte, left hand
M25.751 Osteophyte, right hip
M25.752 Osteophyte, left hip
M25.761 Osteophyte, right knee
M25.762 Osteophyte, left knee
M25.771 Osteophyte, right ankle
M25.772 Osteophyte, left ankle
M25.774 Osteophyte, right foot
M25.775 Osteophyte, left foot
M35.7 Hypermobility syndrome
M45.0 Ankylosing spondylitis of multiple sites in spine
M45.1 Ankylosing spondylitis of occipito-atlanto-axial region
M45.2 Ankylosing spondylitis of cervical region
M45.3 Ankylosing spondylitis of cervicothoracic region
M45.4 Ankylosing spondylitis of thoracic region
M45.5 Ankylosing spondylitis of thoracolumbar region
M45.6 Ankylosing spondylitis lumbar region
M45.7 Ankylosing spondylitis of lumbosacral region
M45.8 Ankylosing spondylitis sacral and sacrococcygeal region
M46.02 Spinal enthesopathy, cervical region
M46.03 Spinal enthesopathy, cervicothoracic region
M46.04 Spinal enthesopathy, thoracic region
M46.05 Spinal enthesopathy, thoracolumbar region
M46.06 Spinal enthesopathy, lumbar region
M46.07 Spinal enthesopathy, lumbosacral region
M46.08 Spinal enthesopathy, sacral and sacrococcygeal region
M46.09 Spinal enthesopathy, multiple sites in spine
M46.82 Other specified inflammatory spondylopathies, cervical region
M46.83 Other specified inflammatory spondylopathies, cervicothoracic region
M46.84 Other specified inflammatory spondylopathies, thoracic region
M46.85 Other specified inflammatory spondylopathies, thoracolumbar region
M46.86 Other specified inflammatory spondylopathies, lumbar region
M46.87 Other specified inflammatory spondylopathies, lumbosacral region
M46.88 Other specified inflammatory spondylopathies, sacral and sacrococcygeal region
M46.89 Other specified inflammatory spondylopathies, multiple sites in spine
M48.8X2 Other specified spondylopathies, cervical region
M48.8X3 Other specified spondylopathies, cervicothoracic region
M48.8X4 Other specified spondylopathies, thoracic region
M48.8X5 Other specified spondylopathies, thoracolumbar region
M48.8X6 Other specified spondylopathies, lumbar region
M48.8X7 Other specified spondylopathies, lumbosacral region
M48.8X8 Other specified spondylopathies, sacral and sacrococcygeal region
M49.82 Spondylopathy in diseases classified elsewhere, cervical region
M49.83 Spondylopathy in diseases classified elsewhere, cervicothoracic region
M49.84 Spondylopathy in diseases classified elsewhere, thoracic region
M49.85 Spondylopathy in diseases classified elsewhere, thoracolumbar region
M49.86 Spondylopathy in diseases classified elsewhere, lumbar region
M49.87 Spondylopathy in diseases classified elsewhere, lumbosacral region
M49.88 Spondylopathy in diseases classified elsewhere, sacral and sacrococcygeal region
M49.89 Spondylopathy in diseases classified elsewhere, multiple sites in spine
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M53.3 Sacrococcygeal disorders, not elsewhere classified
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.821 Other myositis, right upper arm
M60.822 Other myositis, left upper arm
M60.831 Other myositis, right forearm
M60.832 Other myositis, left forearm
M60.841 Other myositis, right hand
M60.842 Other myositis, left hand
M60.851 Other myositis, right thigh
M60.852 Other myositis, left thigh
M60.861 Other myositis, right lower leg
M60.862 Other myositis, left lower leg
M60.871 Other myositis, right ankle and foot
M60.872 Other myositis, left ankle and foot
M60.88 Other myositis, other site
M60.89 Other myositis, multiple sites
M65.221 Calcific tendinitis, right upper arm
M65.222 Calcific tendinitis, left upper arm
M65.231 Calcific tendinitis, right forearm

Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: *Use G56.01 and G56.02 for Carpal Tunnel Syndrome. ONLY CPT 20526 may be used with this diagnosis code.

*Use G57.61, G57.62 or G57.63 for Morton's metatarsalgia, neuralgia, or neuroma. NOTE: ONLY CPT 64455 or 64632 may be used with this diagnosis code.

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ICD-10 Codes that DO NOT Support Medical Necessity

Group 1 Paragraph: All ICD-10-CM codes not listed in this policy under ICD-10-CM Codes that Support Medical Necessity above.

Group 1 Codes: N/A

Additional ICD-10 Information N/A

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