Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA07.047g


Attachment:A

Policy #:MA07.047g

Description:

Title:Pain Management of Peripheral Nerves by Injection


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.



NOT MEDICALLY NECESSARY

THE FOLLOWING CODES ARE CONSIDERED NOT MEDICALLY NECESSARY WHEN REPORTED WITH 64450:

E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma

E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma

E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma

E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy

E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema

E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema

E08.36 Diabetes mellitus due to underlying condition with diabetic cataract

E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication

E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified

E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy

E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy

E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy

E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy

E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological complication

E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene

E08.59 Diabetes mellitus due to underlying condition with other circulatory complications

E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy

E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy

E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis

E08.621 Diabetes mellitus due to underlying condition with foot ulcer

E08.622 Diabetes mellitus due to underlying condition with other skin ulcer

E08.628 Diabetes mellitus due to underlying condition with other skin complications

E08.630 Diabetes mellitus due to underlying condition with periodontal disease

E08.638 Diabetes mellitus due to underlying condition with other oral complications

E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma

E08.65 Diabetes mellitus due to underlying condition with hyperglycemia

E08.69 Diabetes mellitus due to underlying condition with other specified complication

E08.8 Diabetes mellitus due to underlying condition with unspecified complications

E08.9 Diabetes mellitus due to underlying condition without complications

E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemichyperosmolar coma (NKHHC)

E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma

E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma

E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma

E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy

E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema

E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema

E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract

E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication

E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified

E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy

E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy

E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy

E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy

E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication

E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene

E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications

E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy

E09.618 Drug or chemical induced diabetes mellitus with other diabetic arthropathy

E09.620 Drug or chemical induced diabetes mellitus with diabetic dermatitis

E09.621 Drug or chemical induced diabetes mellitus with foot ulcer

E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer

E09.628 Drug or chemical induced diabetes mellitus with other skin complications

E09.630 Drug or chemical induced diabetes mellitus with periodontal disease

E09.638 Drug or chemical induced diabetes mellitus with other oral complications

E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma

E09.649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma

E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia

E09.69 Drug or chemical induced diabetes mellitus with other specified complication

E09.8 Drug or chemical induced diabetes mellitus with unspecified complications

E09.9 Drug or chemical induced diabetes mellitus without complications

E10.10 Type 1 diabetes mellitus with ketoacidosis without coma

E10.11 Type 1 diabetes mellitus with ketoacidosis with coma

E10.21 Type 1 diabetes mellitus with diabetic nephropathy

E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease

E10.29 Type 1 diabetes mellitus with other diabetic kidney complication

E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema

E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema

E10.36 Type 1 diabetes mellitus with diabetic cataract

E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication

E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified

E10.49 Type 1 diabetes mellitus with other diabetic neurological complication

E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene

E10.59 Type 1 diabetes mellitus with other circulatory complications

E10.618 Type 1 diabetes mellitus with other diabetic arthropathy

E10.620 Type 1 diabetes mellitus with diabetic dermatitis

E10.621 Type 1 diabetes mellitus with foot ulcer

E10.622 Type 1 diabetes mellitus with other skin ulcer

E10.628 Type 1 diabetes mellitus with other skin complications

E10.630 Type 1 diabetes mellitus with periodontal disease

E10.638 Type 1 diabetes mellitus with other oral complications

E10.641 Type 1 diabetes mellitus with hypoglycemia with coma

E10.649 Type 1 diabetes mellitus with hypoglycemia without coma

E10.65 Type 1 diabetes mellitus with hyperglycemia

E10.69 Type 1 diabetes mellitus with other specified complication

E10.8 Type 1 diabetes mellitus with unspecified complications

E10.9 Type 1 diabetes mellitus without complications

E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma

E11.10 Type 2 diabetes mellitus with ketoacidosis without coma

E11.11 Type 2 diabetes mellitus with ketoacidosis with coma

E11.21 Type 2 diabetes mellitus with diabetic nephropathy

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

E11.29 Type 2 diabetes mellitus with other diabetic kidney complication

E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

E11.36 Type 2 diabetes mellitus with diabetic cataract

E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication

E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified

E11.49 Type 2 diabetes mellitus with other diabetic neurological complication

E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene

E11.59 Type 2 diabetes mellitus with other circulatory complications

E11.618 Type 2 diabetes mellitus with other diabetic arthropathy

E11.620 Type 2 diabetes mellitus with diabetic dermatitis

E11.621 Type 2 diabetes mellitus with foot ulcer

E11.622 Type 2 diabetes mellitus with other skin ulcer

E11.628 Type 2 diabetes mellitus with other skin complications

E11.630 Type 2 diabetes mellitus with periodontal disease

E11.638 Type 2 diabetes mellitus with other oral complications

E11.641 Type 2 diabetes mellitus with hypoglycemia with coma

E11.649 Type 2 diabetes mellitus with hypoglycemia without coma

E11.65 Type 2 diabetes mellitus with hyperglycemia

E11.69 Type 2 diabetes mellitus with other specified complication

E11.8 Type 2 diabetes mellitus with unspecified complications

E11.9 Type 2 diabetes mellitus without complications

E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemichyperosmolar coma (NKHHC)

E13.01 Other specified diabetes mellitus with hyperosmolarity with coma

E13.10 Other specified diabetes mellitus with ketoacidosis without coma

E13.11 Other specified diabetes mellitus with ketoacidosis with coma

E13.21 Other specified diabetes mellitus with diabetic nephropathy

E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease

E13.29 Other specified diabetes mellitus with other diabetic kidney complication

E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication

E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified

E13.41 Other specified diabetes mellitus with diabetic mononeuropathy

E13.42 Other specified diabetes mellitus with diabetic polyneuropathy

E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy

E13.44 Other specified diabetes mellitus with diabetic amyotrophy

E13.49 Other specified diabetes mellitus with other diabetic neurological complication

E13.59 Other specified diabetes mellitus with other circulatory complications

E13.620 Other specified diabetes mellitus with diabetic dermatitis

E13.621 Other specified diabetes mellitus with foot ulcer

E13.622 Other specified diabetes mellitus with other skin ulcer

E13.628 Other specified diabetes mellitus with other skin complications

E13.638 Other specified diabetes mellitus with other oral complications

E13.641 Other specified diabetes mellitus with hypoglycemia with coma

E13.649 Other specified diabetes mellitus with hypoglycemia without coma

E13.65 Other specified diabetes mellitus with hyperglycemia

E13.69 Other specified diabetes mellitus with other specified complication

E13.8 Other specified diabetes mellitus with unspecified complications

E13.9 Other specified diabetes mellitus without complications

E78.1 Pure hyperglyceridemia

G56.00 Carpal tunnel syndrome, unspecified upper limb

G56.01 Carpal tunnel syndrome, right upper limb

G56.02 Carpal tunnel syndrome, left upper limb

G56.03 Carpal tunnel syndrome, bilateral upper limbs

G57.60 Lesion of plantar nerve, unspecified lower limb

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

M10.9 Gout, unspecified

M12.871 Other specific arthropathies, not elsewhere classified, right ankle and foot

M12.872 Other specific arthropathies, not elsewhere classified, left ankle and foot

M12.879 Other specific arthropathies, not elsewhere classified, unspecified ankle and foot

M12.9 Arthropathy, unspecified

M16.9 Osteoarthritis of hip, unspecified

M17.9 Osteoarthritis of knee, unspecified

M19.90 Unspecified osteoarthritis, unspecified site

M24.20 Disorder of ligament, unspecified site

M24.211 Disorder of ligament, right shoulder

M24.212 Disorder of ligament, left shoulder

M24.219 Disorder of ligament, unspecified shoulder

M24.221 Disorder of ligament, right elbow

M24.222 Disorder of ligament, left elbow

M24.229 Disorder of ligament, unspecified elbow

M24.231 Disorder of ligament, right wrist

M24.232 Disorder of ligament, left wrist

M24.239 Disorder of ligament, unspecified wrist

M24.241 Disorder of ligament, right hand

M24.242 Disorder of ligament, left hand

M24.249 Disorder of ligament, unspecified hand

M24.251 Disorder of ligament, right hip

M24.252 Disorder of ligament, left hip

M24.259 Disorder of ligament, unspecified hip

M24.271 Disorder of ligament, right ankle

M24.272 Disorder of ligament, left ankle

M24.273 Disorder of ligament, unspecified ankle

M24.274 Disorder of ligament, right foot

M24.275 Disorder of ligament, left foot

M24.276 Disorder of ligament, unspecified foot

M24.28 Disorder of ligament, vertebrae

M25.151 Fistula, right hip

M25.152 Fistula, left hip

M25.159 Fistula, unspecified hip

M25.171 Fistula, right ankle

M25.172 Fistula, left ankle

M25.173 Fistula, unspecified ankle

M25.174 Fistula, right foot

M25.175 Fistula, left foot

M25.176 Fistula, unspecified foot

M25.511 Pain in right shoulder

M25.512 Pain in left shoulder

M25.519 Pain in unspecified shoulder

M25.551 Pain in right hip

M25.552 Pain in left hip

M25.559 Pain in unspecified hip

M25.561 Pain in right knee

M25.562 Pain in left knee

M25.569 Pain in unspecified knee

M25.571 Pain in right ankle and joints of right foot

M25.572 Pain in left ankle and joints of left foot

M25.579 Pain in unspecified ankle and joints of unspecified foot

M25.671 Stiffness of right ankle, not elsewhere classified

M25.672 Stiffness of left ankle, not elsewhere classified

M25.673 Stiffness of unspecified ankle, not elsewhere classified

M25.674 Stiffness of right foot, not elsewhere classified

M25.675 Stiffness of left foot, not elsewhere classified

M25.676 Stiffness of unspecified foot, not elsewhere classified

M25.70 Osteophyte, unspecified joint

M25.711 Osteophyte, right shoulder

M25.712 Osteophyte, left shoulder

M25.719 Osteophyte, unspecified shoulder

M25.751 Osteophyte, right hip

M25.752 Osteophyte, left hip

M25.759 Osteophyte, unspecified hip

M25.771 Osteophyte, right ankle

M25.772 Osteophyte, left ankle

M25.773 Osteophyte, unspecified ankle

M25.774 Osteophyte, right foot

M25.775 Osteophyte, left foot

M25.776 Osteophyte, unspecified foot

M25.851 Other specified joint disorders, right hip

M25.852 Other specified joint disorders, left hip

M25.859 Other specified joint disorders, unspecified hip

M25.871 Other specified joint disorders, right ankle and foot

M25.872 Other specified joint disorders, left ankle and foot

M25.879 Other specified joint disorders, unspecified ankle and foot

M25.9 Joint disorder, unspecified

M46.1 Sacroiliitis, not elsewhere classified

M60.80 Other myositis, unspecified site

M60.811 Other myositis, right shoulder

M60.812 Other myositis, left shoulder

M60.819 Other myositis, unspecified shoulder

M60.821 Other myositis, right upper arm

M60.822 Other myositis, left upper arm

M60.829 Other myositis, unspecified upper arm

M60.831 Other myositis, right forearm

M60.832 Other myositis, left forearm

M60.839 Other myositis, unspecified forearm

M60.841 Other myositis, right hand

M60.842 Other myositis, left hand

M60.849 Other myositis, unspecified hand

M60.851 Other myositis, right thigh

M60.852 Other myositis, left thigh

M60.859 Other myositis, unspecified thigh

M60.861 Other myositis, right lower leg

M60.862 Other myositis, left lower leg

M60.869 Other myositis, unspecified lower leg

M60.871 Other myositis, right ankle and foot

M60.872 Other myositis, left ankle and foot

M60.879 Other myositis, unspecified ankle and foot

M60.88 Other myositis, other site

M60.89 Other myositis, multiple sites

M60.9 Myositis, unspecified

M62.40 Contracture of muscle, unspecified site

M62.411 Contracture of muscle, right shoulder

M62.412 Contracture of muscle, left shoulder

M62.419 Contracture of muscle, unspecified shoulder

M62.421 Contracture of muscle, right upper arm

M62.422 Contracture of muscle, left upper arm

M62.429 Contracture of muscle, unspecified upper arm

M62.431 Contracture of muscle, right forearm

M62.432 Contracture of muscle, left forearm

M62.439 Contracture of muscle, unspecified forearm

M62.441 Contracture of muscle, right hand

M62.442 Contracture of muscle, left hand

M62.449 Contracture of muscle, unspecified hand

M62.451 Contracture of muscle, right thigh

M62.452 Contracture of muscle, left thigh

M62.459 Contracture of muscle, unspecified thigh

M62.461 Contracture of muscle, right lower leg

M62.462 Contracture of muscle, left lower leg

M62.469 Contracture of muscle, unspecified lower leg

M62.471 Contracture of muscle, right ankle and foot

M62.472 Contracture of muscle, left ankle and foot

M62.479 Contracture of muscle, unspecified ankle and foot

M62.48 Contracture of muscle, other site

M62.49 Contracture of muscle, multiple sites

M62.831 Muscle spasm of calf

M62.838 Other muscle spasm

M65.9 Synovitis and tenosynovitis, unspecified

M70.60 Trochanteric bursitis, unspecified hip

M70.61 Trochanteric bursitis, right hip

M70.62 Trochanteric bursitis, left hip

M70.70 Other bursitis of hip, unspecified hip

M70.71 Other bursitis of hip, right hip

M70.72 Other bursitis of hip, left hip

M75.30 Calcific tendinitis of unspecified shoulder

M75.31 Calcific tendinitis of right shoulder

M75.32 Calcific tendinitis of left shoulder

M75.40 Impingement syndrome of unspecified shoulder

M75.41 Impingement syndrome of right shoulder

M75.42 Impingement syndrome of left shoulder

M75.80 Other shoulder lesions, unspecified shoulder

M75.81 Other shoulder lesions, right shoulder

M75.82 Other shoulder lesions, left shoulder

M75.90 Shoulder lesion, unspecified, unspecified shoulder

M75.91 Shoulder lesion, unspecified, right shoulder

M75.92 Shoulder lesion, unspecified, left shoulder

M76.00 Gluteal tendinitis, unspecified hip

M76.01 Gluteal tendinitis, right hip

M76.02 Gluteal tendinitis, left hip

M76.10 Psoas tendinitis, unspecified hip

M76.11 Psoas tendinitis, right hip

M76.12 Psoas tendinitis, left hip

M76.20 Iliac crest spur, unspecified hip

M76.21 Iliac crest spur, right hip

M76.22 Iliac crest spur, left hip

M76.30 Iliotibial band syndrome, unspecified leg

M76.31 Iliotibial band syndrome, right leg

M76.32 Iliotibial band syndrome, left leg

M76.60 Achilles tendinitis, unspecified leg

M76.61 Achilles tendinitis, right leg

M76.62 Achilles tendinitis, left leg

M76.70 Peroneal tendinitis, unspecified leg

M76.71 Peroneal tendinitis, right leg

M76.72 Peroneal tendinitis, left leg

M76.811 Anterior tibial syndrome, right leg

M76.812 Anterior tibial syndrome, left leg

M76.819 Anterior tibial syndrome, unspecified leg

M76.821 Posterior tibial tendinitis, right leg

M76.822 Posterior tibial tendinitis, left leg

M76.829 Posterior tibial tendinitis, unspecified leg

M76.899 Other specified enthesopathies of unspecified lower limb, excluding foot

M77.30 Calcaneal spur, unspecified foot

M77.31 Calcaneal spur, right foot

M77.32 Calcaneal spur, left foot

M77.40 Metatarsalgia, unspecified foot

M77.41 Metatarsalgia, right foot

M77.42 Metatarsalgia, left foot

M77.50 Other enthesopathy of unspecified foot and ankle

M77.51 Other enthesopathy of right foot and ankle

M77.52 Other enthesopathy of left foot and ankle

M77.9 Enthesopathy, unspecified

M79.10 Myalgia, unspecified site

M79.11 Myalgia of mastication muscle

M79.12 Myalgia of auxiliary muscles, head and neck

M79.18 Myalgia, other site

M79.7 Fibromyalgia

M79.9 Soft tissue disorder, unspecified

M79.A9 Nontraumatic compartment syndrome of other sites

Q68.8 Other specified congenital musculoskeletal deformities

Q79.8 Other congenital malformations of musculoskeletal system

Q79.9 Congenital malformation of musculoskeletal system, unspecified

S43.421A Sprain of right rotator cuff capsule, initial encounter

S43.421D Sprain of right rotator cuff capsule, subsequent encounter

S43.421S Sprain of right rotator cuff capsule, sequela

S43.422A Sprain of left rotator cuff capsule, initial encounter

S43.422D Sprain of left rotator cuff capsule, subsequent encounter

S43.422S Sprain of left rotator cuff capsule, sequela

S43.429A Sprain of unspecified rotator cuff capsule, initial encounter

S43.429D Sprain of unspecified rotator cuff capsule, subsequent encounter

S43.429S Sprain of unspecified rotator cuff capsule, sequela

Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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