01/08/2020    David Secord, DPM

Cost-Effective Option for Sclerosing Injections? (Brad Toll, DPM)

As Dr. Toll is using the term "sclerosing" and
that he follows Dr. Dockery's method of using 4%
dehydrated EtOH (which is not a high enough
concentration to cause sclerosis), I was
wondering what code he is using? I'll submit a
response to that question from the late great
Harry Goldsmith, DPM:

“Sclerosing is a term that implies a change to
the tissue, in this case, nerve. It is not
necessarily associated with destruction.
Typically, your alcohol product package insert
will note that 40% or greater alcohol solutions
are destructive to peripheral nerves. If you are
sclerosing a nerve using less than 40% alcohol
solution, you are not destroying it, and you
cannot use either CPT 64632 or CPT 64640. In all
likelihood, because a number of doctors report
improvement in symptoms ranging from little/no
to complete resolution, the effect is
therapeutic.

I would tell you that you would code that
injection as CPT 64450 - peripheral nerve block,
therapeutic - regardless of the nerve injected.
Having said that, I would caution you to check
with the particular payer to see if they have
any written policies limiting your coding or
directing you to "its preferred" code. If your
alcohol solution is 40% or greater (you'd better
be sure you've read the literature studies on
those concentrations), then if you are injecting
an intermetatarsal neuroma, you would code the
injection as CPT 64632. A peripheral nerve
elsewhere on the foot, CPT 64640. You would not
bill CPT 64455 - injection(s), anesthetic agent
and/or steroid, plantar common digital nerve(s)
(e.g., Morton's neuroma) - because you are not
injecting cortisone as your therapeutic agent.”

David Secord, DPM, Corpus Christi, TX

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