The occipital nerve block is one of the more commonly miscoded procedures in headache medicine, and the reason is almost always the same: the note does not say which nerve was injected.
The three nerves, and the codes that follow
There is a dedicated code for the greater occipital nerve and no dedicated code for the lesser, which is where most of the confusion starts.
| Code | Procedure | Notes |
|---|---|---|
| 64405 | Greater occipital nerve — anesthetic and/or steroid injection | The only occipital-specific code. Unilateral as written. |
| 64450 | Other peripheral nerve or branch | Used for the lesser occipital nerve, which has no dedicated code. |
| 64633 / 64634 | Cervical or thoracic facet joint denervation, radiofrequency | Reported per joint, not per nerve. 64634 is the add-on for each additional joint. Relevant where the third occipital nerve is targeted as the C2-C3 medial branch. |
| 64490 / 64491 / 64492 | Cervical or thoracic paravertebral facet joint injection, single / second / third-and-additional level | Image guidance is included in these codes. 64491 and 64492 are add-ons. |
The third occipital nerve is the point people most often get wrong. Blocked as a cutaneous nerve it falls under the peripheral nerve code; targeted as the medial branch supplying the C2-C3 facet joint it belongs in the facet family, where imaging is bundled and reporting is per joint.
Bilateral reporting
64405 describes a unilateral procedure. Bilateral greater occipital nerve blocks are reported with modifier 50 appended, subject to your payer’s bilateral policy. A bilateral greater and lesser block is therefore not one line item: it is the greater occipital code with modifier 50 plus the peripheral nerve code with modifier 50, and it will only survive review if the note names all four nerves separately.
Imaging guidance
Ultrasonic guidance for needle placement is reported with 76942, and is separately reportable alongside 64405 where the payer allows it and the note documents the guidance and retains the image. It is reportable once per patient per day regardless of how many sites were injected.
Two cautions. Separate reimbursement for 76942 is payer-specific and several have restricted it. And where imaging is already included in the primary code — the facet family above — reporting a guidance code separately, particularly with modifier 59, is exactly what contractor guidance warns against.
The documentation that decides the claim
- Name the nerve. Greater, lesser, third, and which side. “Occipital nerve block” alone does not support either code.
- State laterality explicitly for each nerve, not once for the procedure.
- Record the agent and volume, and whether steroid was included — the code covers anesthetic and/or steroid, so the choice does not change the code but it does support medical necessity.
- Document the guidance if you are reporting it: modality, that it was used for needle placement, and that an image was retained.
- Record the response, ideally as a pre- and post-procedure pain score. This is what supports a repeat block later.
Pairing the diagnosis
The diagnosis carries as much weight as the procedure code. M54.81 is occipital neuralgia and is the cleanest pairing where the clinical picture supports it. G44.86 is cervicogenic headache. Where the block is being used in migraine, the migraine code is the one that belongs on the claim, not a neuralgia code chosen because it reads better. The full list is in ICD-10 codes for headache.
Common questions
What is the CPT code for an occipital nerve block?
64405 for the greater occipital nerve. The lesser occipital nerve has no dedicated code and is reported with 64450. Which one applies depends entirely on what the note says was injected.
Is there a separate code for a bilateral occipital nerve block?
No. 64405 is unilateral and bilateral is reported with modifier 50, subject to your payer’s bilateral policy.
Can I bill ultrasound guidance with 64405?
Where the payer allows it, yes — 76942, once per patient per day, with the guidance documented and an image retained. Several payers have restricted separate payment, so check before assuming.
Which ICD-10 code should go with it?
M54.81 for occipital neuralgia, G44.86 for cervicogenic headache, or the appropriate migraine code where that is the indication. See ICD-10 codes for headache.
Do you accept referrals for diagnostic blocks specifically?
Yes, and it is a common reason for referral — a guided block that does not relieve the pain excludes a target, which a landmark block cannot do. See referring to us.
Reference, not billing advice. Codes change annually, and coverage differs by payer and by Medicare Administrative Contractor. Verify against the current-year CPT code book and your payer’s current policy before submitting. CPT® is a registered trademark of the American Medical Association; descriptions here are abbreviated for identification.