How To Use CPT Code 64418

CPT 64418 describes the injection of an anesthetic agent and/or steroid near the suprascapular nerve, which is located above the shoulder blade. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 64418?

CPT 64418 is used to report the injection of an anesthetic agent and/or steroid close to the suprascapular nerve. This nerve is situated above the triangular bone at the back of the shoulder, known as the shoulder blade. The code is used when one or more injections are administered during a single procedure.

2. Official Description

The official description of CPT code 64418 is: ‘Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve.’ There are no additional notes provided for this code.

3. Procedure

1. The provider prepares the patient for the procedure.
2. Using a needle and syringe, the provider administers one or more injections of an anesthetic agent and/or steroid close to the suprascapular nerve.
3. This nerve is a branch of the brachial plexus and supplies sensory nerves to the shoulder joint and motor nerves to the rotator muscles.
4. The purpose of the procedure is to anesthetize the area supplied by the nerve and provide relief from chronic shoulder pain caused by conditions such as inflammatory arthritis, bursitis, frozen shoulder syndrome, or as analgesia after shoulder surgery.
5. In some cases, the procedure may also be performed for diagnostic purposes.

4. Qualifying circumstances

CPT 64418 is performed when a patient experiences chronic shoulder pain due to conditions such as inflammatory arthritis, bursitis, or frozen shoulder syndrome. The procedure may also be performed for analgesia after shoulder surgery or for diagnostic purposes. It is important to note that the injection(s) must be administered close to the suprascapular nerve.

5. When to use CPT code 64418

CPT code 64418 should be used when the provider administers one or more injections of an anesthetic agent and/or steroid close to the suprascapular nerve. This code is appropriate for reporting the procedure when it is performed for therapeutic or diagnostic purposes. It is important to ensure that the injection(s) are administered in the correct location.

6. Documentation requirements

To support a claim for CPT 64418, the provider must document the following information:

• Patient’s diagnosis and the need for the injection(s)
• Specific details of the injection(s) administered, including the type of anesthetic agent and/or steroid used
• Date and time of the procedure
• Location of the injection(s) near the suprascapular nerve
• Reason for the procedure (therapeutic or diagnostic)
• Any additional relevant information, such as the patient’s response to the injection(s)
• Provider’s signature

7. Billing guidelines

When billing for CPT 64418, ensure that the injection(s) are administered close to the suprascapular nerve. There are no specific guidelines regarding reporting this code with other codes. However, it is important to follow any applicable bundling or modifier guidelines provided by payers. It is recommended to review the payer’s policies and guidelines to ensure accurate and appropriate billing.

8. Historical information

CPT 64418 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone a recent change on January 1, 2020, where the description was updated to ‘Injection, anesthetic agent; suprascapular nerve.’

9. Examples

1. A patient with inflammatory arthritis receives an injection of an anesthetic agent and steroid close to the suprascapular nerve to alleviate chronic shoulder pain.
2. Following shoulder surgery, a patient receives an injection of an anesthetic agent near the suprascapular nerve for post-operative analgesia.
3. A provider performs a diagnostic injection of an anesthetic agent close to the suprascapular nerve to determine the source of a patient’s shoulder pain.
4. A patient with frozen shoulder syndrome receives an injection of an anesthetic agent and steroid near the suprascapular nerve to improve range of motion and alleviate pain.
5. A provider administers an injection of an anesthetic agent close to the suprascapular nerve to provide temporary relief from bursitis-related shoulder pain.
6. For a patient with chronic shoulder pain, a provider performs an injection of an anesthetic agent and steroid near the suprascapular nerve to manage the symptoms of inflammatory arthritis.
7. A patient with a history of shoulder pain receives an injection of an anesthetic agent close to the suprascapular nerve for diagnostic purposes.
8. A provider administers an injection of an anesthetic agent and steroid near the suprascapular nerve to alleviate chronic shoulder pain caused by rotator cuff tendinitis.
9. Following a shoulder injury, a patient receives an injection of an anesthetic agent close to the suprascapular nerve to manage acute pain and facilitate rehabilitation.
10. A provider performs a diagnostic injection of an anesthetic agent near the suprascapular nerve to determine the cause of a patient’s shoulder impingement syndrome.