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2025 CPT code 64405

Injection(s) of anesthetic and/or steroid into the greater occipital nerve.

Follow all relevant CPT coding guidelines regarding nerve blocks, including those concerning the reporting of imaging guidance and the use of modifiers for bilateral procedures (modifier 50).

Modifier 50 (Bilateral Procedure) can be applied if injections were performed on both sides.Modifiers may also be used to clarify the type of imaging guidance if reported separately.

Medical necessity for a greater occipital nerve block is established when a patient presents with chronic headaches consistent with occipital neuralgia or cervicogenic headaches.Conservative treatment options (e.g., medication, physical therapy) have been deemed ineffective, and the procedure is expected to provide significant pain relief or assist in establishing a diagnosis.

The physician performs the injection procedure after appropriate patient preparation. This involves using a needle and syringe to administer the anesthetic and/or steroid near the greater occipital nerve to anesthetize the supplied area. This procedure is used for diagnostic or therapeutic purposes to treat occipital neuralgia or cervicogenic headaches.

IMPORTANT:For injection or destruction of genicular nerve branches, see codes 64454 and 64624 respectively.For intracranial surgery on cranial nerves, see codes 61450, 61460, and 61790. For destruction by neurolytic agent or chemodenervation, see codes 62280-62282 and 64600-64681. For epidural or subarachnoid injection, see codes 62320-62327.

In simple words: The doctor injects medicine (anesthetic and/or steroid) near the greater occipital nerve in the back of the head to relieve headache pain or diagnose a nerve problem.This is sometimes called an occipital nerve block.

This CPT code describes the procedure of injecting an anesthetic agent and/or steroid into the greater occipital nerve.The injection(s) may be performed for diagnostic or therapeutic purposes to alleviate occipital neuralgia or cervicogenic headaches.Imaging guidance, if used, may be reported separately unless specifically included within the code's definition. The code is reported once per nerve, regardless of the number of injections administered.

Example 1: A patient presents with chronic occipital neuralgia unresponsive to conservative management. The physician performs a greater occipital nerve block (64405) to provide pain relief., A patient experiences persistent headaches suspected to originate from the greater occipital nerve. The physician performs a diagnostic greater occipital nerve block (64405) to assess the source of the pain and guide further treatment., A patient with cervicogenic headaches, stemming from issues in the upper cervical spine, undergoes a therapeutic greater occipital nerve block (64405) to reduce pain and improve function.The injection includes a steroid to reduce inflammation.

* Detailed history and physical examination documenting the patient's headache symptoms, including location, duration, character, and associated symptoms.* Imaging studies (if performed), such as X-rays, CT scans, or MRI, to rule out other potential causes of headaches.* Documentation of previous treatments and their effectiveness.* Precise location of the injection site and technique used during the procedure.* Volume and type of anesthetic and/or steroid administered.* Assessment of the patient's response to the injection, both immediately following the procedure and during subsequent follow-up visits.* Documentation of any adverse effects experienced by the patient.

** This procedure may be performed using fluoroscopy or ultrasound guidance. If ultrasound guidance is utilized, the imaging may be billed separately using the appropriate CPT code.Always consult the most recent CPT manual for complete coding guidelines.

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