A Closer Look At Practice Management Aspects Of Treating Heel Pain

Author(s): 
By Lowell Weil Jr., DPM, MBA

Pertinent Insights On Coding For Cortisone Injections
When these initial treatment options do not successfully control the heel pain, more aggressive alternatives may become necessary. A cortisone injection is a very effective adjunctive treatment to the heel pain treatment regimen. It is my belief that one should only utilize cortisone after initiating proper mechanical control of the foot and addressing the factors that initially caused the problem.
At that point, cortisone can be very helpful. However, cortisone injections to the heel have a very traumatic reputation with regard to procedural pain. Many times, I have heard patients state that a cortisone injection to their heel was the most painful experience of their life. To obviate that, I always perform a local anesthetic, medial calcaneal nerve block several minutes prior to the introduction of the cortisone injection. This nerve block significantly reduces the pain associated with the cortisone injection and allows greater ease in performing the cortisone injection.
One should bill both the nerve block and the actual cortisone injection in these circumstances. Code the nerve block as CPT 64450 and bill the cortisone injection as CPT 20550. Additionally, in selected cases, if one has a musculoskeletal ultrasound available, you can utilize it to help target the placement of the cortisone injection and help facilitate greater success. This is especially helpful with a fragmented heel spur. One would code this additional tool as CPT 76942. It is unusual for me to utilize more than two cortisone injections for the treatment of plantar fasciitis and I usually do not go beyond a single injection.
When the aforementioned treatment regimen fails over a period of four to six months, it is necessary to consider more aggressive treatment alternatives. It has been my experience that most people will respond to the above treatment. However, in the cases of failure, we have often found that the plantar fascia itself has changed and become scarred and thickened. This entity is more appropriately termed plantar fasciosis.

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