APMA News - January/February 2022 - 44

coding
Therapeutic versus
Destructive Nerve Injections
By R. Alex Dellinger, DPM, and Mitchell P. Hilsen, DPM
Physicians perform many types of injections on
the human body for a variety of medical conditions.
Injections may be targeted to specific tissues.
The goal of this article is to discuss two types of
nerve injections: therapeutic and destructive, and
to review the relevant coding associated with
them. Let's begin with some medical definitions:
* Injection: Use of a syringe and needle to push
fluids or drugs into the body.
* Therapeutic: Relating to the treatment of
disease or disorders by remedial agents
or methods.
* Destructive: Causing ruin or destruction; the
opposite of constructive.
Thus, a therapeutic nerve injection can be
defined as the use of a syringe and needle to
introduce remedial agents to treat a diseased
or disordered nerve. A destructive injection can
be defined as the use of a syringe and needle to
introduce an agent causing ruin or destruction
to a nerve. The literature is replete with articles
describing therapeutic nerve injections as well as
articles studying destructive nerve injections. This
article is not meant to be a literature review, but
rather to highlight that sometimes, the intent of a
physician is to treat a nerve disorder, and sometimes
it is to destroy a nerve.
Some commonly injected therapeutic agents
include corticosteroids, non-steroidal anti-inflammatory
agents, and local anesthetics. As far as
destructive agents, the most commonly studied
substance is dehydrated ethyl alcohol. According
to the product information sheet from Akorn Inc.,
a manufacturer of dehydrated alcohol USP, the
clinical pharmacology of dehydrated alcohol is that
" alcohol produces injury to tissue cells by dehydration
and precipitation of protoplasm. When alcohol
is injected in close proximity to nerve tissues, it
produces neuritis and nerve degeneration (neurolysis). "
There is no definitive data defining the specific
concentration of alcohol injections to affect a
permanent neurolysis to specific nerves, but the
medical literature suggests destruction of the nerve
occurs with concentrations of 30-100-percent
dehydrated alcohol.
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apmanews
JANUARY/FEBRUARY 2022
Coding for Therapeutic and
Destructive Injections
The CPT coding manual includes many options for
coding injections. CPT codes 64600-64681 are
under the category of Destruction by Neurolytic
Agent (e.g., Chemical, Thermal, Electrical, or
Radiofrequency), Chemodenervation. This section
is not specific for injections; the codes describe
any procedure to confer destruction to a nerve,
whether it is through injection, radiofrequency, or
another modality.
CPT codes 64400-64530 are under the category
heading of Introduction/Injection of Anesthetic
Agent (Nerve Block), Diagnostic or Therapeutic.
Unlike the 64600-64681 codes, these codes are
only used for injections. The CPT manual states
these codes are not to be used for destruction by a
neurolytic agent or chemodenervation.
Let's review some specific codes that are relevant
to the foot and ankle:
CPT 64632: Destruction by neurolytic agent;
plantar common digital nerve.
Based on the language in the CPT manual,
and by the above definitions, this code could
be reported when the intent is to destroy the
plantar common digital nerve, whether through
an injection, radiofrequency procedure, or other
modality. Could this code be used when injecting
a 4-percent-alcohol solution? According to
the literature, it takes concentrations of alcohol
between 30-100 percent to render a permanent
neurolysis. We are not aware of any study
that demonstrates a 4-percent-alcohol solution
renders a permanent neurolysis, therefore CPT
64632 should not be reported when a 4-percent-alcohol
solution is injected to the plantar
common digital nerve.
CPT 64640: Destruction by neurolytic agent;
other peripheral nerve branch.
This code has been reported by some foot and
ankle specialists when injecting nerves other than
the plantar common digital nerve. The same logic
as CPT 64632 would apply: if a destructive procedure
is performed on another peripheral nerve
branch, this code is applicable if the doctor injects
a destructive concentration of alcohol or uses
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