How To Use CPT Code 64488

CPT 64488 describes the bilateral transversus abdominis plane (TAP) block procedure, which involves injecting a local anesthetic to provide pain relief for lower abdominal surgery. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 64488?

CPT 64488 is used to describe the bilateral transversus abdominis plane (TAP) block procedure. This procedure involves injecting a local anesthetic to provide analgesia, or pain relief, for lower abdominal surgery. The TAP block targets the nerves that supply the abdominal wall above the umbilicus, helping to reduce post-operative pain and improve patient comfort.

2. Official Description

The official description of CPT code 64488 is: ‘Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed)’

3. Procedure

1. During the TAP block procedure, the healthcare provider prepares the patient and administers anesthesia.
2. The provider identifies the triangle of petit, a depression between the external oblique muscle and latissimus dorsi muscle, and inserts a needle into the skin.
3. Using imaging guidance, such as ultrasound, the provider advances the needle until they hear a pop sound, indicating that the needle is at the external oblique muscle fascia.
4. The provider further advances the needle until they hear a second pop sound, indicating that the needle is in the internal oblique muscle fascia.
5. Once the needle is in the correct position, the provider injects a local anesthetic to provide pain relief.
6. The provider continuously monitors the spread of the anesthetic and may reposition the needle if necessary.
7. The procedure is performed bilaterally to ensure pain relief on both sides of the abdomen.

4. Qualifying circumstances

CPT 64488 is typically performed for patients undergoing lower abdominal surgery who require post-operative pain management. The procedure is suitable for patients who would benefit from targeted pain relief in the abdominal wall above the umbilicus. It is important to note that the TAP block is performed by injections and includes imaging guidance, such as ultrasound, when necessary.

5. When to use CPT code 64488

CPT code 64488 should be used when a healthcare provider performs a bilateral TAP block procedure using injections to provide pain relief for lower abdominal surgery. This code is appropriate when the procedure is performed bilaterally and includes imaging guidance, such as ultrasound, if needed.

6. Documentation requirements

To support a claim for CPT 64488, the healthcare provider must document the following information:

• Patient’s diagnosis or reason for the TAP block procedure
• Details of the procedure, including the use of imaging guidance
• Date and time of the procedure
• Specific anatomical landmarks used for needle insertion
• Type and amount of local anesthetic administered
• Monitoring of the spread of the anesthetic
• Any additional procedures or interventions performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 64488, ensure that the procedure is performed bilaterally and includes injections and imaging guidance, if necessary. It is important to follow the specific documentation requirements and guidelines provided by the payer. Additionally, do not report CPT 64488 with other codes that may overlap or duplicate the services provided.

8. Historical information

CPT 64488 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoing lower abdominal surgery receives a bilateral TAP block to manage post-operative pain.
2. A healthcare provider performs a TAP block using injections and imaging guidance for a patient undergoing a hernia repair.
3. A patient scheduled for a cesarean section receives a bilateral TAP block to provide pain relief after the surgery.
4. A healthcare provider administers a TAP block using injections and ultrasound guidance for a patient undergoing a hysterectomy.
5. A patient undergoing appendectomy receives a bilateral TAP block to minimize post-operative pain.
6. A healthcare provider performs a TAP block using injections and imaging guidance for a patient undergoing a tummy tuck procedure.
7. A patient undergoing colorectal surgery receives a bilateral TAP block to manage pain during the recovery period.
8. A healthcare provider administers a TAP block using injections and ultrasound guidance for a patient undergoing an ovarian cyst removal.
9. A patient scheduled for a gallbladder removal receives a bilateral TAP block to provide pain relief after the surgery.
10. A healthcare provider performs a TAP block using injections and imaging guidance for a patient undergoing a kidney transplant.