Clinical Policy Title: Ambulatory continuous peripheral nerve block for chronic pain

Transcription

1 Clinical Policy Title: Ambulatory continuous peripheral nerve block for chronic pain Clinical Policy Number: Effective Date: December 1, 2017 Initial Review Date: October 19, 2017 Most Recent Review Date: November 16, 2017 Next Review Date: November 2018 Related policies: Policy contains: Continuous peripheral nerve block. Chronic pain. Perineural infusion. CP# CP# CP# CP# CP# CP# CP# CP# CP# CP# CP# CP# CP# CP# CP# Parenteral treatment for complex regional pain syndrome Implantable infusion pumps Radiofrequency ablation treatment for spine pain Acupuncture Spine pain facet joint injection Intrathecal opioid therapy for chronic nonmalignant pain Spinal cord stimulators for chronic pain Spine pain epidural steroid injections Spine pain trigger point injection Biofeedback for chronic pain Intravenous lidocaine infusion for neuropathic pain Invasive treatment for cervicogenic headache and occipital neuralgia Sphenopalatine ganglion block injections for headache Genicular nerve block Hierarchy of chronic pain management ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select Health of South Carolina s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Select Health of South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of South Carolina s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies as necessary. Select Health of South Carolina s clinical policies are not guarantees of payment. Coverage policy Select Health of South Carolina considers the routine use of a continuous peripheral nerve block (cpnb) for the management of chronic pain in an ambulatory setting to be investigational and, therefore, not medically necessary. 1

2 Limitations: None. For Medicare members: Select Health of South Carolina considers the use of cpnb to be reasonable and necessary for Medicare members with: Chronic pain conditions or hyperhidroses that respond to nerve blocks (e.g., celiac block for pain of pancreatic cancer) (Medicare Local Coverage Decisions [LCDs] L34289 and L34289). Peripheral nerve injuries/entrapment or other extremity trauma leading to complex regional pain syndrome (CRPS) (L35456, L35457). Alternative covered services: Standards of care involve a range of multimodal approaches depending on pain severity and underlying condition, including but not limited to: Non-pharmacologic interventions (e.g., acupuncture, physical therapy and exercise, cognitive behavioral therapy, and mindfulness meditation). Systemic opioid and non-opioid pharmacotherapy. Local anesthetic injections. Epidural or intrathecal regional infusions. Neuroablation. Neurostimulation. Surgical intervention. Background Chronic pain involves pain signals that persist for weeks, months, or even years. Acute events or chronic conditions can create ongoing pain, but it may occur in the absence of any past injury or evidence of body damage (American Academy of Pain Medicine [AAPM], 2017). Commonly reported causes of chronic pain include headache, low back pain, cancer pain, arthritis pain, and neurogenic pain, often with significant consequences to quality of life, overall health, and society. An estimated 100 million Americans suffer from chronic pain, affecting every age group (Tsang, 2088). Risk factors for chronic pain conditions include: speaking English as a second language; African American and Hispanic ethnicity; lower income and education; cognitive impairment; surgery; and cancer (Institute of Medicine [IOM], 2011). Adult Medicaid populations experience a higher burden of migraine headaches, neck pain, lower back pain, or pain the face or jaw than those with private insurance, Medicare only coverage, or no insurance (Pleis, 2010). Limited data suggest chronic pain is a significant and underreported problem in the pediatric population (Ilfeld, 2011). 2

3 Those with an underlying propensity or increased risk for chronic pain are also at risk for under-treatment, as chronic pain can be challenging to treat. The goals of treatment are to decrease pain intensity and functional outcomes, such as improving independence in activities of daily living, participating in activities, or optimizing cognition, mood, or sleep (National Academies of Sciences, Engineering, and Medicine [NASEM], 2017). Prescription opioids are effective analgesics for chronic pain, but their long-term use is associated with an increased risk of opioid use disorder (OUD), death from opioid overdose, and other adverse outcomes (e.g., cardiovascular events or fractures). In the context of the growing opioid problem, reducing the burden of suffering from chronic pain poses a significant public health challenge. NASEM (2017) proposed multidisciplinary and multimodal non-opioid approaches to reduce the burden of opioid misuse and abuse and manage pain more effectively. Interventional neuromodulation therapies deliver pharmaceutical agents, electrical signals, or other forms of energy directly to the pain source, thereby avoiding side effects associated with more systemic or irreversible treatments, and are reversible. They increase the flexibility of both duration and density of local anesthetic effect depending on the chosen dose. A PNB is neuromodulatory therapy delivered as a single injection or by continuous infusion. Single-injection PNB offers effective pain relief for up to 24 hours but requires a dense motor block, and important sensory loss must be taken into account (Aguirre, 2012). Continuous peripheral nerve blockade (cpnb) comprises an indwelling catheter, a long-acting local anesthetic, and an infusion pump (Aguirre, 2012). Guided by nerve stimulation, ultrasound guidance, paresthesia induction, fluoroscopic imaging, or simple tactile perceptions, the catheter is inserted percutaneously in the proximity of the target nerve to deliver local anesthetic, most commonly bupivacaine and ropivacaine (Ilfeld, 2017; Aguirre, 2012). Multiple small portable infusion pumps are available, each with benefits and limitations. cpnb is most often used for post-surgical pain control in the hospital setting, but lightweight, portable pumps allow for ambulatory infusion as well. cpnb offers adjustments of volume or concentration of local anesthetic, which reduces the need for a large initial bolus, lowers the risk of systemic toxicity, falls, and positioning injury, and potentially improves patient outcome (Aguirre, 2012). Searches Select Health of South Carolina searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services (CMS). We conducted searches on September 29, Search terms were: Nerve Block/methods (MeSH), Chronic Pain (Mesh), and free text terms continuous peripheral nerve block and perineural infusion. We included: 3

4 Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings We identified one systematic review (Hayes, 2017), three narrative reviews (Ilfeld, 2017; Aguirre, 2012; Ilfeld, 2011) and seven evidence-based guidelines (National Comprehensive Cancer Network [NCCN], 2017; Paice, 2016; Neal, 2015; Blumenfeld, 2013; Manchikanti, 2013; Martelletti, 2013; Horlocker, 2010). The overwhelming majority of studies of cpnb involve perioperative analgesia in adults and is the only application validated with randomized controlled clinical trials (RCTs). Low-quality, retrospective studies have described experience with cpnb in hundreds of pediatric post-surgical patients (Ilfeld, 2011). Ambulatory cpnb for perioperative pain control is at least as effective as sham, single-injection PNBs, and neuraxial routes of analgesia for controlling pain, decreasing opioid consumption and opioid-related side effects, decreasing nausea, and providing greater patient satisfaction (Bingham, 2012). Prolonged benefits of regional anesthesia after catheter removal were reported in a minority of patients. Evidence of longterm outcomes such as decreased chronic pain and improved health-related quality of life (HRQOL) are lacking (Bingham, 2012; Aguirre, 2012). The evidence of ambulatory cpnb for chronic pain indications is anecdotal, consisting of case reports and small case series describing cpnb in adult and pediatric populations for CRPS, intractable phantom limb pain, terminal cancer pain, trigeminal neuralgia, postsurgical chronic (> three months) pain syndromes, ischemia-induced pain, and ulcer-derived pain (Hayes, 2017; Ilfeld, 2017; Ilfeld, 2011). The evidence suggests cpnb is feasible and may offer effective analgesia for certain chronic pain types that would respond to a PNB, but the relative safety or efficacy to other treatment options, optimal delivery, or patient selection criteria cannot be determined. The experience with ambulatory cpnb in the perioperative pain settings offers some insight into its potential use for chronic pain. Regardless of technique or block location, major complications of PNB, though rare, include vascular puncture and bleeding, nerve damage, infection, and local anesthetic systemic toxicity; minor complications involve catheter dislodgement, obstruction, and fluid leakage at the catheter site (Aguirre, 2012). Ambulatory support systems that are evidence-based and incorporate rapid diagnosis and early treatment algorithms can positively influence patient outcomes (Neal, 2015). The complexity associated with an indwelling catheter and pump assembly raises the likelihood of technique failure. Successful home use of cpnb depends on appropriate patient selection, adequate 4

5 ambulatory care support to detect and address adverse events promptly, and education on pump management and catheter removal (Aguirre, 2012). While age alone is not an absolute exclusion criterion, patients for whom cpnb may not be appropriate include those with (Ilfeld, 2011): Known renal and hepatic insufficiency to avoid possible local anesthetic toxicity. Heart disease, lung disease, or obesity who may not be able to compensate for mild hypoxia or hypercarbia (interscalene and cervical paravertebral infusions). Altered mental status or psychosocial issues that prevent understanding of, or cooperation with, protocol and care requirements. Inability to be contacted after discharge or to access a medical facility in case of emergency. Evidence-based guidelines provide little direction on the optimal use of cpnb in chronic non-malignant pain care. Where PNB is mentioned as a treatment option, guidelines recommend single-injection PNB as an alternative when more conservative treatment has failed, with no specific mention of continuous delivery systems except when recommending neuraxial techniques (Neal, 2015; Blumenfeld, 2013; Manchikanti, 2013; Martelletti, 2013; Horlocker, 2010). The American Society of Regional Anesthesia and Pain (2017) does not mention continuous infusion of PNB in their list of treatment options for chronic pain. For malignant pain, the American Society of Clinical Oncology (Paice, 2016) recommends PNBs as an interventional therapy option based on a Cochrane review (Arcidiacono, 2011) demonstrating improved pain and lower opioid consumption at four weeks in adults receiving a single-injection celiac plexus block for pancreatic cancer pain. Neither the review nor the guideline specifically mentioned continuous infusion except with neuraxial techniques. NCCN (2017) recommends cpnb as one of several regional infusion options in adults. Interventional approaches using regional infusions are generally not appropriate in the presence of ongoing infection, coagulopathy, very short life expectancy, distorted anatomy, patient unwillingness, medications that increase risk of bleeding, or unavailable technical expertise. Catheter displacement and infection generally limit use beyond a few days or weeks. The main patient selection criteria are: Pain that is likely to be relieved with a nerve block (e.g., pancreas/upper abdomen with celiac plexus block or lower abdomen with superior hypogastric plexus block, or peripheral/plexus nerve). Inability to achieve adequate analgesia or functional activities of daily living with other pharmacologic therapy. Presence of intolerable side effects from other interventions (e.g., opioid titration program). Policy updates: None. Summary of clinical evidence: 5

6 Citation Hayes (2017) Comparative effectiveness review of paravertebral block (PVB) for prevention of chronic pain after breast surgery (some chronic pain data reported) Ilfeld (2017) cpnbs: an update of the published evidence and comparison with novel, alternative analgesic modalities Bingham (2012) cpnb v. single-injection PNB (sipnb) Ilfeld (2011) Content, Methods, Recommendations Key points: Systematic review of seven randomized controlled trials (RCTs), one prospective cohort study, two retrospective cohort studies, one retrospective comparative database study with propensity matching, and two retrospective case series. Sample sizes 43 to 1,152 patients undergoing breast cancer surgery. Follow-up ranged three to 12 months postsurgery. Overall quality: Low with high risk of bias. Underpowered, adjunctive therapies used, and nonrandomized designs. Pain control: Three RCTs found statistically significant differences favoring cpvb as an adjunct to single-injection PVB (sipvb) or cpvb with either gabapentin or pregabalin v. comparator. One RCT found no significant difference between cpvb with or without adjunctive treatment. Analgesia use: Three RCTs found mixed results. HRQOL: Three RCTs found mixed results. cpvb not clearly superior to sipvb or general anesthesia alone. Aggregated data for all PVB regimens suggest low complication rates but inconclusive impact on mortality and recurrence- and disease-free survival. Key points: Narrative review update of evidence published since Restricted to RCTs and most influential case reports and observational studies. Included 17 new case reports and small case series on chronic pain conditions: cancerrelated pain (six articles), CRPS (four articles), ischemia-induced pain (two articles), ulcer-derived pain (one article), and phantom limb pain (four articles, including one small RCT with three patients). A prolonged ambulatory cpnb is feasible and may be a reliable treatment for chronic pain conditions, but RCTs are warranted. Advances in disposable pump technology include the ability to adjust basal rates, bolus volume, and lockout times, deliver repeated bolus doses at intervals set by the provider, and remotely communicate with the pump via the Internet. Greater widespread adoption of ultrasound guidance over nerve stimulation may improve complication rates. Key points: Systematic review and meta-analysis of 21 RCTs (702 patients). Trial sample size ranged from 16 to 155 patients. Overall quality: Fair (13 RCTs) to high (eight RCTs) based on Jadad scale. Compared with sipnbs, cpnbs were associated with statistically significant improvement in pain control through post-op day 2, decrease in overall opioid use, decrease in nausea, and higher patient satisfaction scores. The effect of cpnbs on other clinically relevant outcomes, such as complications, longterm functional outcomes, or costs, remains unclear. Not endorsed for universal pain management at this time. Key points: cpnbs: a review of the published evidence Comprehensive narrative review of clinical indications, catheter insertion techniques, infusates, infusion pumps, ambulatory perineural infusion, benefits, and complications. 6

7 Citation Content, Methods, Recommendations The overwhelming majority of evidence involves perioperative application of cpnb and is the only application validated with RCTs, including nine RCTs of home cpnb for postoperative analgesia. Four case reports and small case series described cpnb to treat chronic pain in CRPS, intractable phantom limb pain, cancer pain, and trigeminal neuralgia (one study each). Most frequently used drugs are ropivacaine, bupivacaine, and levobupivacaine because of longer duration of action and favorable sensory motor block ratio. Optimal catheter insertion modality and technique, infusate(s) and adjuvants, local anesthetic delivery regimen, ambulatory infusion, possible infusion benefits, and the incidence of all possible risks have not been determined. Age is not an absolute exclusion criterion, as complication rates or severity in pediatric and adult patients receiving at-home CPNB appear comparable. Comparison of perineural infusion to possible new analgesic techniques is needed. References Professional society guidelines/other: Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. Headache. 2013; 53(3): /head Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010; 35(1): Manchikanti L, Abdi S, Atluri S, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013; 16(2 Suppl): S Martelletti P, Jensen RH, Antal A, et al. Neuromodulation of chronic headaches: position statement from the European Headache Federation. J Headache Pain. 2013; 14: / NCCN Guidelines Version Adult Cancer Pain. NCCN website. Accessed October 5, Neal JM, Barrington MJ, Brull R, et al. The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine: Executive Summary Reg Anesth Pain Med. 2015; 40(5): /AAP Paice JA, Portenoy R, Lacchetti C, et al. Management of Chronic Pain in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. Journal of Clinical Oncology. 2016; 34(27): /jco

8 Treatment options for chronic pain. American Society of Regional Anesthesia and Pain website. Accessed October 8, Peer-reviewed references: AAPM Facts and Figures on Pain. AAPM website. Accessed October 3, Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012; 2012: /2012/ Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011; (3): Cd / CD pub2. Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with singleinjection peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2012; 37(6): /AAP.0b013e31826c351b. Committee on Advancing Pain Research, Care, and Education; Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: Committee on Advancing Pain Research, Care, and Education; Institute of Medicine; National Academies Press website. Accessed October 4, Hayes Inc., Hayes Medical Technology Report. Comparative Effectiveness Review of Paravertebral Block for Prevention of Chronic Pain After Breast Surgery. Lansdale, Pa. Hayes Inc.; August 3, Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg. 2011; 113(4): /ANE.0b013e e01. Ilfeld BM. Continuous Peripheral Nerve Blocks: An Update of the Published Evidence and Comparison with Novel, Alternative Analgesic Modalities. Anesth Analg. 2017; 124(1): /ane NASEM. Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use National Academies Press website. Accessed October 4, Pleis JR WB, Lucas JW Summary Health Statistics for U.S. Adults: National Health Interview Survey, National Center for Health Statistics. Vital Health Stat. 2010; 10(249). 8

9 Tsang A, Von Korff M, Lee S, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008; 9(10): /j.jpain CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. A53432 Anesthetic 'Caine Drugs'. CMS website. Accessed October 6, Anesthetic drugs such as Bupivacaine (Marcaine), Bupivacaine (Sensorcaine), Chloroprocaine (Nesacaine), Lidocaine (Xylocaine), Mepivacaine (Carbocaine), etc., when administered for chronic pain control are not covered by Medicare. A55239 Implantable Infusion Pumps for Chronic Pain. CMS website. Accessed October 6, Covered for intrathecal or epidural routes only. A55323 Implantable Infusion Pumps for Chronic Pain. CMS website. Accessed October 6, Covered for intrathecal or epidural routes only. Local Coverage Determinations (LCDs): L33593 Implantable Infusion Pump for the Treatment of Chronic Intractable Pain. CMS website. Accessed October 6, Covered for intrathecal or epidural delivery of morphine only. L35456 Nerve Blockade for Treatment of Chronic Pain and Neuropathy. CMS website. Accessed October 6, L35457 Nerve Blockade for Treatment of Chronic Pain and Neuropathy. CMS website. Accessed October 6, L33933 Peripheral Nerve Blocks. CMS website. Accessed October 6, Addresses PNB for normally temporary conditions. No coverage for treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases. L36850 Peripheral Nerve Blocks. CMS website. Accessed October 6, Addresses PNB for 9

10 normally temporary conditions. No coverage for treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases. L34289 Surgery: Continuous Peripheral Nerve Blocks (CPNB). CMS website. Accessed October 6, Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or ct) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or ct) Injection, anesthetic agent; facial nerve Injection, anesthetic agent; greater occipital nerve Injection, anesthetic agent; vagus nerve Injection, anesthetic agent; phrenic nerve Injection, anesthetic agent; cervical plexus Injection, anesthetic agent; brachial plexus, single Injection, anesthetic agent; axillary nerve Injection, anesthetic agent; suprascapular nerve Injection, anesthetic agent; intercostal nerve, single Injection, anesthetic agent; intercostal nerves, multiple, regional block Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves Injection, anesthetic agent; pudendal nerve 10

11 CPT Code Description Comments Injection, anesthetic agent; paracervical (uterine) nerve Injection, anesthetic agent; sciatic nerve, single Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement) Injection, anesthetic agent; femoral nerve, single Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) Injection, anesthetic agent; other peripheral nerve or branch Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, morton's neuroma) Paravertebral block (pvb) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed) Paravertebral block (pvb) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (list separately in addition to code for primary procedure) Paravertebral block (pvb) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or ct); cervical or thoracic, single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or ct); cervical or thoracic, each additional level (list separately in addition to code for primary procedure) Injection, anesthetic agent; sphenopalatine ganglion Injection, anesthetic agent; carotid sinus (separate procedure) Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Injection, anesthetic agent; superior hypogastric plexus Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring Destruction by neurolytic agent, intercostal nerve Destruction by neurolytic agent; plantar common digital nerve Destruction by neurolytic agent; other peripheral nerve or branch Injection, anesthetic agent; other peripheral nerve or branch Ultrasound, extremity, nonvascular, real-time with image documentation; complete Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Unlisted ultrasound procedure (eg, diagnostic, interventional) Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Unlisted therapeutic procedure (specify) ICD-10 Code Description Comments B02.0 Zoster encephalitis 11

12 B02.1 Zoster meningitis B02.21 Postherpetic geniculate ganglionitis B02.22 Postherpetic trigeminal neuralgia B02.23 Postherpetic polyneuropathy B02.24 Postherpetic myelitis B02.29 Other postherpetic nervous system involvement B02.7 Disseminated zoster B02.8 Zoster with other complications B02.9 Zoster without complications G50.0 Trigeminal neuralgia G54.0 Brachial plexus disorders G54.1 Lumbosacral plexus disorders G54.2 Cervical root disorders, not elsewhere classified G54.3 Thoracic root disorders, not elsewhere classified G54.4 Lumbosacral root disorders, not elsewhere classified G54.5 Neuralgic amyotrophy G54.6 Phantom limb syndrome with pain G54.8 Other nerve root and plexus disorders G55 Nerve root and plexus compressions in diseases classified elsewhere G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G56.03 Carpal tunnel syndrome, bilateral upper limbs G56.11 Other lesions of median nerve, right upper limb G56.12 Other lesions of median nerve, left upper limb G56.13 Other lesions of median nerve, bilateral upper limbs G56.21 Lesion of ulnar nerve, right upper limb G56.22 Lesion of ulnar nerve, left upper limb G56.23 Lesion of ulnar nerve, bilateral upper limbs G56.31 Lesion of radial nerve, right upper limb G56.32 Lesion of radial nerve, left upper limb G56.33 Lesion of radial nerve, bilateral upper limbs G56.41 Causalgia of right upper limb G56.42 Causalgia of left upper limb G56.43 Causalgia of bilateral upper limbs G56.81 Other specified mononeuropathies of right upper limb G56.82 Other specified mononeuropathies of left upper limb G56.91 Unspecified mononeuropathy of right upper limb G56.92 Unspecified mononeuropathy of left upper limb G57.01 Lesion of sciatic nerve, right lower limb G57.02 Lesion of sciatic nerve, left lower limb G57.03 Lesion of sciatic nerve, bilateral lower limbs G57.11 Meralgia paresthetica, right lower limb G57.12 Meralgia paresthetica, left lower limb G57.13 Meralgia paresthetica, bilateral lower limbs G57.21 Lesion of femoral nerve, right lower limb G57.22 Lesion of femoral nerve, left lower limb 12

13 G57.23 Lesion of femoral nerve, bilateral lower limbs G57.31 Lesion of lateral popliteal nerve, right lower limb G57.32 Lesion of lateral popliteal nerve, left lower limb G57.33 Lesion of lateral popliteal nerve, bilateral lower limbs G57.41 Lesion of medial popliteal nerve, right lower limb G57.42 Lesion of medial popliteal nerve, left lower limb G57.43 Lesion of medial popliteal nerve, bilateral lower limbs G57.51 Tarsal tunnel syndrome, right lower limb G57.52 Tarsal tunnel syndrome, left lower limb 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 G57.71 Causalgia of right lower limb G57.72 Causalgia of left lower limb G57.73 Causalgia of bilateral lower limbs G57.81 Other specified mononeuropathies of right lower limb G57.82 Other specified mononeuropathies of left lower limb G57.91* Unspecified mononeuropathy of right lower limb G57.92* Unspecified mononeuropathy of left lower limb G58.0 Intercostal neuropathy G58.7* Mononeuritis multiplex G58.8* Other specified mononeuropathies G58.9* Mononeuropathy, unspecified G59* Mononeuropathy in diseases classified elsewhere G89.11 Acute pain due to trauma G89.12 Acute post-thoracotomy pain G89.18 Other acute postprocedural pain G89.21 Chronic pain due to trauma G89.22 Chronic post-thoracotomy pain G89.28 Other chronic postprocedural pain G89.3 Neoplasm related pain (acute) (chronic) G90.50 Complex regional pain syndrome I, unspecified G Complex regional pain syndrome I of right upper limb G Complex regional pain syndrome I of left upper limb G Complex regional pain syndrome I of upper limb, bilateral G Complex regional pain syndrome I of right lower limb G Complex regional pain syndrome I of left lower limb G Complex regional pain syndrome I of lower limb, bilateral G90.59 Complex regional pain syndrome I of other specified site I73.00 Raynaud's syndrome without gangrene I73.01 Raynaud's syndrome with gangrene L Primary focal hyperhidrosis, axilla L Primary focal hyperhidrosis, face L Primary focal hyperhidrosis, palms L Primary focal hyperhidrosis, soles 13

14 M Pain in right shoulder M Pain in left shoulder M Pain in right hip M Pain in left hip M Pain in right knee M Pain in left knee M43.27 Fusion of spine, lumbosacral region M43.28 Fusion of spine, sacral and sacrococcygeal region M46.1 Sacroiliitis, not elsewhere classified M48.01 Spinal stenosis, occipito-atlanto-axial region M48.02 Spinal stenosis, cervical region M48.03 Spinal stenosis, cervicothoracic region M48.04 Spinal stenosis, thoracic region M48.05 Spinal stenosis, thoracolumbar region M Spinal stenosis, lumbar region with neurogenic claudication M50.11 Cervical disc disorder with radiculopathy, high cervical region M Cervical disc disorder at C4-C5 level with radiculopathy M Cervical disc disorder at C5-C6 level with radiculopathy M Cervical disc disorder at C6-C7 level with radiculopathy M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region M50.21 Other cervical disc displacement, high cervical region M Other cervical disc displacement at C4-C5 level M Other cervical disc displacement at C5-C6 level M Other cervical disc displacement at C6-C7 level M50.23 Other cervical disc displacement, cervicothoracic region M50.31 Other cervical disc degeneration, high cervical region M Other cervical disc degeneration at C4-C5 level M Other cervical disc degeneration at C5-C6 level M Other cervical disc degeneration at C6-C7 level M50.33 Other cervical disc degeneration, cervicothoracic region M51.14 Intervertebral disc disorders with radiculopathy, thoracic region M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region M51.16 Intervertebral disc disorders with radiculopathy, lumbar region M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region M51.24 Other intervertebral disc displacement, thoracic region M51.25 Other intervertebral disc displacement, thoracolumbar region M51.34 Other intervertebral disc degeneration, thoracic region M51.35 Other intervertebral disc degeneration, thoracolumbar region M53.0 Cervicocranial syndrome M53.2X7 Spinal instabilities, lumbosacral region M53.2X8 Spinal instabilities, sacral and sacrococcygeal region M53.3 Sacrococcygeal disorders, not elsewhere classified M53.81 Other specified dorsopathies, occipito-atlanto-axial region M53.82 Other specified dorsopathies, cervical region M53.83 Other specified dorsopathies, cervicothoracic region M53.86 Other specified dorsopathies, lumbar region 14

15 M53.87 Other specified dorsopathies, lumbosacral region M53.88 Other specified dorsopathies, sacral and sacrococcygeal region M54.10* Radiculopathy, site unspecified M54.11 Radiculopathy, occipito-atlanto-axial region M54.12 Radiculopathy, cervical region M54.13 Radiculopathy, cervicothoracic region M54.14 Radiculopathy, thoracic region M54.15 Radiculopathy, thoracolumbar region M54.16 Radiculopathy, lumbar region M54.17 Radiculopathy, lumbosacral region M54.18 Radiculopathy, sacral and sacrococcygeal region M54.2 Cervicalgia M54.31 Sciatica, right side M54.32 Sciatica, left side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M54.5 Low back pain M54.6 Pain in thoracic spine M54.81 Occipital neuralgia M79.2* Neuralgia and neuritis, unspecified M94.0 Chondrocostal junction syndrome [Tietze] M96.1 Postlaminectomy syndrome, not elsewhere classified M99.20 Subluxation stenosis of neural canal of head region M99.21 Subluxation stenosis of neural canal of cervical region M99.22 Subluxation stenosis of neural canal of thoracic region M99.30 Osseous stenosis of neural canal of head region M99.31 Osseous stenosis of neural canal of cervical region M99.32 Osseous stenosis of neural canal of thoracic region M99.40 Connective tissue stenosis of neural canal of head region M99.41 Connective tissue stenosis of neural canal of cervical region M99.42 Connective tissue stenosis of neural canal of thoracic region M99.50 Intervertebral disc stenosis of neural canal of head region M99.51 Intervertebral disc stenosis of neural canal of cervical region M99.52 Intervertebral disc stenosis of neural canal of thoracic region M99.60 Osseous and subluxation stenosis of intervertebral foramina of head region M99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical region M99.62 Osseous and subluxation stenosis of intervertebral foramina of thoracic region M99.70 Connective tissue and disc stenosis of intervertebral foramina of head region M99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical region M99.72 Connective tissue and disc stenosis of intervertebral foramina of thoracic region R07.1 Chest pain on breathing R07.81 Pleurodynia R07.9* Chest pain, unspecified R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain 15

16 R10.13 Epigastric pain R10.2 Pelvic and perineal pain R10.30 Lower abdominal pain, unspecified R10.31 Right lower quadrant pain R10.32 Left lower quadrant pain R10.33 Periumbilical pain R25.0 Abnormal head movements R25.1 Tremor, unspecified R25.2 Cramp and spasm R25.3 Fasciculation R25.8 Other abnormal involuntary movements R25.9 Unspecified abnormal involuntary movements R44.0 Auditory hallucinations R44.2 Other hallucinations R44.3 Hallucinations, unspecified R68.84 Jaw pain S14.2XXA Injury of nerve root of cervical spine, initial S14.2XXD Injury of nerve root of cervical spine, subsequent S14.2XXS Injury of nerve root of cervical spine, sequela S14.3XXA Injury of brachial plexus, initial S14.3XXD Injury of brachial plexus, subsequent S14.3XXS Injury of brachial plexus, sequela S14.4XXA Injury of peripheral nerves of neck, initial S14.4XXD Injury of peripheral nerves of neck, subsequent S14.4XXS Injury of peripheral nerves of neck, sequela S14.5XXA Injury of cervical sympathetic nerves, initial S14.5XXD Injury of cervical sympathetic nerves, subsequent S14.5XXS Injury of cervical sympathetic nerves, sequela S14.8XXA Injury of other specified nerves of neck, initial S14.8XXD Injury of other specified nerves of neck, subsequent S14.8XXS Injury of other specified nerves of neck, sequela S14.9XXA Injury of unspecified nerves of neck, initial S14.9XXD Injury of unspecified nerves of neck, subsequent S14.9XXS Injury of unspecified nerves of neck, sequela S24.2XXA Injury of nerve root of thoracic spine, initial S24.2XXD Injury of nerve root of thoracic spine, subsequent S24.2XXS Injury of nerve root of thoracic spine, sequela S24.3XXA Injury of peripheral nerves of thorax, initial S24.3XXD Injury of peripheral nerves of thorax, subsequent S24.3XXS Injury of peripheral nerves of thorax, sequela S24.4XXA Injury of thoracic sympathetic nervous system, initial S24.4XXD Injury of thoracic sympathetic nervous system, subsequent S24.4XXS Injury of thoracic sympathetic nervous system, sequela S24.8XXA Injury of other specified nerves of thorax, initial S24.8XXD Injury of other specified nerves of thorax, subsequent S24.8XXS Injury of other specified nerves of thorax, sequela 16

17 S24.9XXA Injury of unspecified nerve of thorax, initial S24.9XXD Injury of unspecified nerve of thorax, subsequent S24.9XXS Injury of unspecified nerve of thorax, sequela S34.21XA Injury of nerve root of lumbar spine, initial S34.21XD Injury of nerve root of lumbar spine, subsequent S34.21XS Injury of nerve root of lumbar spine, sequela S34.22XA Injury of nerve root of sacral spine, initial S34.22XD Injury of nerve root of sacral spine, subsequent S34.22XS Injury of nerve root of sacral spine, sequela S34.4XXA Injury of lumbosacral plexus, initial S34.4XXD Injury of lumbosacral plexus, subsequent S34.4XXS Injury of lumbosacral plexus, sequela S34.5XXA Injury of lumbar, sacral and pelvic sympathetic nerves, initial S34.5XXD Injury of lumbar, sacral and pelvic sympathetic nerves, subsequent S34.5XXS Injury of lumbar, sacral and pelvic sympathetic nerves, sequela S34.6XXA Injury of peripheral nerve(s) at abdomen, lower back and pelvis level, initial S34.6XXD Injury of peripheral nerve(s) at abdomen, lower back and pelvis level, subsequent S34.6XXS Injury of peripheral nerve(s) at abdomen, lower back and pelvis level, sequela S34.8XXA Injury of other nerves at abdomen, lower back and pelvis level, initial S34.8XXD Injury of other nerves at abdomen, lower back and pelvis level, subsequent S34.8XXS Injury of other nerves at abdomen, lower back and pelvis level, sequela S34.9XXA Injury of unspecified nerves at abdomen, lower back and pelvis level, initial S34.9XXD Injury of unspecified nerves at abdomen, lower back and pelvis level, subsequent S34.9XXS Injury of unspecified nerves at abdomen, lower back and pelvis level, sequela S44.01XA Injury of ulnar nerve at upper arm level, right arm, initial S44.01XD Injury of ulnar nerve at upper arm level, right arm, subsequent S44.01XS Injury of ulnar nerve at upper arm level, right arm, sequela S44.02XA Injury of ulnar nerve at upper arm level, left arm, initial S44.02XD Injury of ulnar nerve at upper arm level, left arm, subsequent S44.02XS Injury of ulnar nerve at upper arm level, left arm, sequela S44.11XA Injury of median nerve at upper arm level, right arm, initial S44.11XD Injury of median nerve at upper arm level, right arm, subsequent S44.11XS Injury of median nerve at upper arm level, right arm, sequela S44.12XA Injury of median nerve at upper arm level, left arm, initial S44.12XD Injury of median nerve at upper arm level, left arm, subsequent S44.12XS Injury of median nerve at upper arm level, left arm, sequela S44.21XA Injury of radial nerve at upper arm level, right arm, initial S44.21XD Injury of radial nerve at upper arm level, right arm, subsequent S44.21XS Injury of radial nerve at upper arm level, right arm, sequela S44.22XA Injury of radial nerve at upper arm level, left arm, initial S44.22XD Injury of radial nerve at upper arm level, left arm, subsequent 17

18 S44.22XS Injury of radial nerve at upper arm level, left arm, sequela S44.30XA Injury of axillary nerve, unspecified arm, initial S44.30XD Injury of axillary nerve, unspecified arm, subsequent S44.30XS Injury of axillary nerve, unspecified arm, sequela S44.31XA Injury of axillary nerve, right arm, initial S44.31XD Injury of axillary nerve, right arm, subsequent S44.31XS Injury of axillary nerve, right arm, sequela S44.32XA Injury of axillary nerve, left arm, initial S44.32XD Injury of axillary nerve, left arm, subsequent S44.32XS Injury of axillary nerve, left arm, sequela S44.41XA Injury of musculocutaneous nerve, right arm, initial S44.41XD Injury of musculocutaneous nerve, right arm, subsequent S44.41XS Injury of musculocutaneous nerve, right arm, sequela S44.42XA Injury of musculocutaneous nerve, left arm, initial S44.42XD Injury of musculocutaneous nerve, left arm, subsequent S44.42XS Injury of musculocutaneous nerve, left arm, sequela S44.51XA Injury of cutaneous sensory nerve at shoulder and upper arm level, right arm, initial S44.51XD Injury of cutaneous sensory nerve at shoulder and upper arm level, right arm, subsequent S44.51XS Injury of cutaneous sensory nerve at shoulder and upper arm level, right arm, sequela S44.52XA Injury of cutaneous sensory nerve at shoulder and upper arm level, left arm, initial S44.52XD Injury of cutaneous sensory nerve at shoulder and upper arm level, left arm, subsequent S44.52XS Injury of cutaneous sensory nerve at shoulder and upper arm level, left arm, sequela S44.8X1A Injury of other nerves at shoulder and upper arm level, right arm, initial S44.8X1D Injury of other nerves at shoulder and upper arm level, right arm, subsequent S44.8X1S Injury of other nerves at shoulder and upper arm level, right arm, sequela S44.8X2A Injury of other nerves at shoulder and upper arm level, left arm, initial S44.8X2D Injury of other nerves at shoulder and upper arm level, left arm, subsequent S44.8X2S Injury of other nerves at shoulder and upper arm level, left arm, sequela S44.91XA Injury of unspecified nerve at shoulder and upper arm level, right arm, initial S44.91XD Injury of unspecified nerve at shoulder and upper arm level, right arm, subsequent S44.91XS Injury of unspecified nerve at shoulder and upper arm level, right arm, sequela S44.92XA Injury of unspecified nerve at shoulder and upper arm level, left arm, initial S44.92XD Injury of unspecified nerve at shoulder and upper arm level, left arm, subsequent S44.92XS Injury of unspecified nerve at shoulder and upper arm level, left arm, sequela S54.01XA Injury of ulnar nerve at forearm level, right arm, initial 18

19 S54.01XD Injury of ulnar nerve at forearm level, right arm, subsequent S54.01XS Injury of ulnar nerve at forearm level, right arm, sequela S54.02XA Injury of ulnar nerve at forearm level, left arm, initial S54.02XD Injury of ulnar nerve at forearm level, left arm, subsequent S54.02XS Injury of ulnar nerve at forearm level, left arm, sequela S54.11XA Injury of median nerve at forearm level, right arm, initial S54.11XD Injury of median nerve at forearm level, right arm, subsequent S54.11XS Injury of median nerve at forearm level, right arm, sequela S54.12XA Injury of median nerve at forearm level, left arm, initial S54.12XD Injury of median nerve at forearm level, left arm, subsequent S54.12XS Injury of median nerve at forearm level, left arm, sequela S54.21XA Injury of radial nerve at forearm level, right arm, initial S54.21XD Injury of radial nerve at forearm level, right arm, subsequent S54.21XS Injury of radial nerve at forearm level, right arm, sequela S54.22XA Injury of radial nerve at forearm level, left arm, initial S54.22XD Injury of radial nerve at forearm level, left arm, subsequent S54.22XS Injury of radial nerve at forearm level, left arm, sequela S54.31XA Injury of cutaneous sensory nerve at forearm level, right arm, initial S54.31XD Injury of cutaneous sensory nerve at forearm level, right arm, subsequent S54.31XS Injury of cutaneous sensory nerve at forearm level, right arm, sequela S54.32XA Injury of cutaneous sensory nerve at forearm level, left arm, initial S54.32XD Injury of cutaneous sensory nerve at forearm level, left arm, subsequent S54.32XS Injury of cutaneous sensory nerve at forearm level, left arm, sequela S54.8X1A Injury of other nerves at forearm level, right arm, initial S54.8X1D Injury of other nerves at forearm level, right arm, subsequent S54.8X1S Injury of other nerves at forearm level, right arm, sequela S54.8X2A Injury of other nerves at forearm level, left arm, initial S54.8X2D Injury of other nerves at forearm level, left arm, subsequent S54.8X2S Injury of other nerves at forearm level, left arm, sequela S54.91XA Injury of unspecified nerve at forearm level, right arm, initial S54.91XD Injury of unspecified nerve at forearm level, right arm, subsequent S54.91XS Injury of unspecified nerve at forearm level, right arm, sequela S54.92XA Injury of unspecified nerve at forearm level, left arm, initial S54.92XD Injury of unspecified nerve at forearm level, left arm, subsequent S54.92XS Injury of unspecified nerve at forearm level, left arm, sequela S64.01XA Injury of ulnar nerve at wrist and hand level of right arm, initial S64.01XD Injury of ulnar nerve at wrist and hand level of right arm, subsequent S64.01XS Injury of ulnar nerve at wrist and hand level of right arm, sequela S64.02XA Injury of ulnar nerve at wrist and hand level of left arm, initial S64.02XD Injury of ulnar nerve at wrist and hand level of left arm, subsequent S64.02XS Injury of ulnar nerve at wrist and hand level of left arm, sequela S64.11XA Injury of median nerve at wrist and hand level of right arm, initial S64.11XD Injury of median nerve at wrist and hand level of right arm, subsequent S64.11XS Injury of median nerve at wrist and hand level of right arm, sequela S64.12XA Injury of median nerve at wrist and hand level of left arm, initial 19