# rhizotomy



## CynthiaT (Dec 30, 2010)

I am new to pain management coding & need help with the following rhizotomy procedure.  I am not clear how to code because of the dorsal rami...?

*Procedure Performed: * Bilateral medial branch neurotomy, radiofrequency denervation for L4, dorsal rami at L5, dorsal rami at S1 (to address bilateral L5-S1 facet joints) utilizing fluoroscopy and MAC.

*Procedure:*
The patient was identified. A written and informed consent was obtained. Vital signs were evaluated and monitored throughout the procedure. IV access was obtained in the upper limb. The patient was presented to the fluoroscopy suite where she was positioned prone. Anesthesiologist provided MAC during the procedure. The skin overlying the lumbar and sacral region was thoroughly cleansed with Betadine solution and draped in a sterile fashion. Fluoroscopy was utilized to identify the predicted locations for the medial branch of L4. The dorsal rami of L5 and communicating breast at S1 on the right. The skin overlying these injection sites was anesthetized with 1% buffered lidocaine and a 27-gauge 1.5-inch syringe following negative aspirations for blood to produce the subcutaneous and intermuscular wheal. This was followed by penetration with a 20-gauge, 10 mm, 10 cm RV cannula. Curved-tip radiofrequency needle was advanced to the appropriate locations as directed by fluoroscopy utilizing AP, oblique, and lateral views. Once the periosteal contact was made and placement was confirmed, the impedance was checked followed by motor stimulation which was negative for distal contraction, but positive for multifidus and paraspinal contraction followed by sensory stimulation which was evaluated and determined to be positive before proceeding. The patient then received an injection of 0.5 mL of a mixture of 4 mL of 4% lidocaine and 1 mL of betamethasone (6 mg/mL) at each of the injection site prior to receiving 90 seconds of radiofrequency denervation at 90 degrees Celsius at each of the three locations specified. The needles were then removed. Identical format was carried down on the left at the three injection sites specified. Again, prior to placement of the radiofrequency needles, the patient received subcutaneous and intermuscular injection with 1% buffered lidocaine following negative aspirations for blood. Placement was checked for impedance, motor contraction, and sensory stimulation prior to proceeding with the 90 seconds of radiofrequency denervation. Prior to denervation, additionally, she received 0.5 mL of injectant following negative aspirations for blood and/or CSF at each of these three locations and identical format to the right. The stylets were replaced and the needles were withdrawn. The skin overlying the lumbar and sacral region was thoroughly cleansed. There was no evidence of intravascular or intraneural injection. There were no complications with the procedure. The patient was returned to the recovery area where she received postprocedure instructions from the nursing staff and from myself. She was stable and ambulatory upon the time of discharge. She will follow up with us in clinic tomorrow.


Thanks, in advance, for your help!!


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## dwaldman (Dec 30, 2010)

If this was a facet block this would be a one level block, but according CPT Assistant Sep 04 dennervation is billed per facet joint nerve destruction instead of facet joint level.

    L4 medial branch bilateral 64622-50
    L5 dorsal ramus bilateral 64623-50
    S1 Communicating branch bilateral 64623-50 

You could place additional note on the claim stating:

 3 Separate Nerves  Bilateral


To potentially prevent duplication denial of the third line on claim


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