# how to code rfa @ t9,t10,t11



## annieledesma (May 22, 2015)

I need help with coding this. I think it would be 64633x1 and 64634x2. 


Pre Procedure Diagnosis:  mid back pain/posterior element pain secondary  to facet disease
Post Procedure Diagnosis:  Same

Procedure:   1. Radiofrequency Ablation of thoracic medial branches at Right 
                      T9, T10, T11
                      2. Fluoroscopic Guidance and needle localization


Procedure in Detail: 

After informing the patient of the risk and benefits of the procedure including infection, bleeding  and increased pain as well as possible spinal injury, the patient was brought to the operating room and placed in a prone position.  
The patient was given  moderate IV sedation/MAC per anesthesia/CRNA. 

 After prepping and draping  the patient's skin in a sterile fashion, the patient's spine was studied  under fluoroscopy and after injecting the skin at the intended needle trajectory with a 1% lidocaine solution, a set of 20 gauge 10mm active tip RFK needle was advanced toward the junction between the superior articular process and transverse process of right T9, T10 & T11 levels using standard techniques as set forth by the ISIS and ASIPP guidelines. After contacting the periosteum, each of the needles were further adjusted for correct placement by sliding the needle around/across the groove/junction of each of the joint levels at the correct anatomic location of the traversing medial branch. 

At this point, each of the medial branches   was further tested for correct needle placement by stimulating each of the nerves with standard sensory and motor signals using standard algorithm.
Patient had appropriate sensory paresthesia locally at below 1volt 50 Hz stimulation and there was no distal motor root effect at upto 1.5volts at 2Hz stimulation.

After above,  each of the medial branches  was blocked with 1 cc volume of injectant , which was a  mixture of 6 mg with betamethasone in a 6 cc volume  of 0.5% bupivacaine solution. After this,  each nerve was lesioned multiple times at 85 deg Celsius at 90second interval, by moving the RFK needle slightly above and below each of the lesion site.

The patient tolerated the procedure well and was discharged to PACU and reevaluated before being discharged home  with follow up instructions/Post procedure instructions. The patient was again reminded of possible flareup pain in the first 1-2 weeks.


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## dwaldman (May 23, 2015)

T9, T10 medial branches innervate T10-11
T10, T11 medial branches innervate T11-T12

So this would represent  2 facet levels treated with modifier RT:

64633  
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

64634  
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)  

721.2  
Thoracic spondylosis without myelopathy  

From ICD-10 perspective, the choices are thoracic or thoracolumbar, when looking at thoracolumbar I saw this definition and wasn't sure if they had an official definition for the crossing of spinal regions (which vertebrae to count)

 "the  back region that encompasses the tenth thoracic vertebra through the first lumbar vertebra."

So from ICD-10 perspective I guess it would fall under the below because radiculopathy nor myelopathy were not mentioned as being present:

M47.814  
Spondylosis without myelopathy or radiculopathy, thoracic region


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## annieledesma (Jul 9, 2015)

Thank you for your help. 

When you say "innervate" does that mean that in order to ablate medial branches @t9,t10,t11 he has to ablate mb @t10-t11, t11-t12. I'm a little confused about the innveration process. Do you know where I get the info on what innervates what?

But from what I'm understanding if the doctor ablates t1,t2,t3,t4 this wouldn't be 4 levels, instead it would be 

t1-t2 innervate t2-t3
t2-t3 innervate t3-t4
t3-t4 innervate t4-t5


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## dwaldman (Jul 14, 2015)

You would be counting by facet joint even though they are targeting the facet joint nerves , which provides like you stated 4 nerves being treated but only 3 facet joint levels. The thing I have found is it is not  something you can do a quick internet search and find a lot information about facet joint innervation that ties in the coding aspect. Below is from AMA CPT Assistant & an article I did find on the internet that I had seen before, but sometimes the anatomy being describes can get complex pretty quick when the articles are written for other physicians that are real familiar with the anatomy. In regards, to your question if I knew where to find more information with understanding the facet joint innervation, I have noticed pain management coding consultant Marvel J Hammer RN BS CPC CCS-P ACS-PM CPCO is very familiar with this anatomy and how to  accurately abstract the code selection to appropriately report these types of procedures which can be difficult because each physician can documented them differently. This chart below which I hope I retyped correctly is example of tool that I obtained from a webinar that I attended by the mentioned consultant in the above post.

C1,C2 -C1-2
C2, 3----C2-3
C3,4----C4-5
C4,5----C5-6
C6,C7---C6-7
C7,C8----C7-T1
C8, T1----T1-2
T1,2-----T2-3
T2,3----T3-4
T3,4----T4-5
T4,5-----T5-6
T5,6-----T6-7
T6,7-----T7-8
T7,8----T8-9
T8,9----T9-10
T9,10---T10-11
T10,11----T11-12
T11-12---T12-L1
T12, L1---L1-2
L1,2----L2-3
L2,3---L3-4
L3,4---L4-5
L4,5----L5-S1

______________________________


AMA CPT Assistant Feb 2015

Although two nerves innervate each facet joint, the number of nerves treated does not affect code selection. This is reflected in the term "nerve(s)" which is included in the code descriptors. Therefore, only one unit of service may be reported for each joint regardless of the number of nerves treated. To clarify, the typical patient has two nerves treated for each facet joint. These nerves are at two different vertebral levels; however, the code is reported once per joint treated no matter how many nerves are treated. 

_________________________________________________

The Role Of Radiofrequency Facet Denervation In Chronic Low Back Pain

Jerry A. Hall, M.D.

http://www.coccyx.org/medabs/hall.htm


The medial branch gives off two sets of branches to the zygapophyseal joints, named by Bogduk and Long the proximal and distal zygapophyseal joints. The proximal zygapophyseal nerve supplies the rostral aspect of the next lower joint. Thus, each zygapophyseal nerve from the medial branch related to it laterally, and the distal zygapophyseal nerve from the next rostral segment. This fact has important implications for facet nerve block and denervation procedures, as both branches need to be blocked or lesioned to completely denervate a single joint.



The course of the medial branch of the dorsal ramus is fixed anatomically at two points: at its origin near the superior aspect of the base of the transverse process, and distally where it emerges from the canal formed by the mammillo-accessory ligament. No reported variations of this anatomy have been found in the literature to date.9

At the L5 level, the transverse process is replaced by the sacral ala, and the L5 dorsal ramus arises from the spinal nerve just outside the L5-S1 intervertebral foramen, passing dorsally over the sacral ala in a groove formed by the junction of the ala with the root of the superior articular process of the sacrum. The medial branch arises as the nerve passes in this groove, and then wraps medially around the posterior aspect of the lumbosacral (L5-S1) zygapophyseal joint, terminating in the multifidus muscle.


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