Headache procedure coding reference

Codes for the headache procedures performed here, beyond the occipital nerve, with the reporting rules that most often cause a denial.

Autonomic and cranial nerve blocks

Code	Procedure	Notes
64505	Sphenopalatine ganglion block	Covers the transnasal topical approach used here. No needle is involved in that route.
64510	Stellate ganglion block (cervical sympathetic)	Performed under ultrasound.
64400	Trigeminal nerve, any division or branch	Covers supraorbital, supratrochlear and other superficial branches — see supraorbital neuralgia.

The trigeminal and occipital codes are distinct and should not be conflated when both territories are treated at one sitting. Each nerve treated needs to be named in the note for either to hold up.

Chemodenervation for chronic migraine

Code	Procedure	Notes
64615	Chemodenervation of muscles innervated by the facial, trigeminal, cervical spinal and accessory nerves, bilateral	Written as inherently bilateral, so modifier 50 does not apply. This is the code built for the PREEMPT protocol.
J0585	OnabotulinumtoxinA, per unit	Billed separately from 64615, which covers the injection work and not the drug. The chronic migraine protocol is 155 units across 31 sites.

Two things sink these claims. Reporting 64615 with modifier 50 — the descriptor already says bilateral. And a diagnosis that does not support chronic migraine: the indication requires 15 or more headache days a month, and the trials below that threshold did not demonstrate benefit. See who qualifies.

Cervical interventions

Code	Procedure	Notes
64490 / 64491 / 64492	Cervical or thoracic paravertebral facet joint injection — first / second / third-and-additional level	Image guidance is included. 64491 and 64492 are add-ons to 64490.
64633 / 64634	Cervical or thoracic facet joint denervation by radiofrequency — first joint / each additional joint	Reported per joint, not per nerve, one unit per joint.
20552 / 20553	Trigger point injection — one or two muscles / three or more muscles	Reported once per session regardless of the number of injections. Not for dry needling.

These matter in headache because the upper cervical joints refer into the head — see cervicogenic headache. The per-joint rather than per-nerve convention for denervation is the most common reporting error in this group.

Infusion for an attack that will not break

Code	Procedure	Notes
96365 / 96366	Therapeutic IV infusion — initial hour / each additional hour	The initial code requires an infusion beyond 15 minutes.
96374 / 96375	Therapeutic IV push — initial substance / each additional sequential substance	An administration of 15 minutes or less is a push, not an infusion.

The distinction between a push and an infusion is decided by documented time, and an infusion documented at under 16 minutes belongs in the push family. Where several agents are given in sequence, the hierarchy rules determine which single service is primary. See IV migraine therapy.

Imaging guidance

76942, ultrasonic guidance for needle placement, is reportable once per patient per day where the payer allows separate payment and the note documents the guidance with a retained image. Do not report a guidance code alongside a procedure whose descriptor already includes imaging — the facet family above being the case that catches people.

Common questions

Does 64615 take modifier 50?

No. The descriptor is already bilateral, so appending modifier 50 is a reporting error rather than a way to capture both sides.

How is the drug reported for chronic migraine chemodenervation?

Separately, as J0585 per unit. 64615 covers the injection work only.

Is the sphenopalatine block coded differently when done transnasally?

64505 covers the block. The transnasal topical route is what we use — see the SPG block explained.

Can facet denervation be reported per nerve?

No — per joint, one unit per joint denervated, with 64634 as the add-on for each additional joint.