# RF of SA-S1?



## kseeg23 (Jul 1, 2014)

I have a radiofrequency note that looks like this:

LUMBAR RADIOFREQUENCY ABLATION WITH FLUOROSCOPY
TARGET SITES: L4, L5, SACRAL ALA AND S1 (to denerve the joints at L3-4, L4-5,L5-SA and SA-S1) Right 

I ask the Dr was "SA" is and im told its like a "nub" or something. Does that actually count as a joint or should it still just be written as L5-S1 and only coded as 3 levels? I'm not really sure how to code it or what it means exactly.

Also, just so I can clear up some issues here at the office, Is L3-L4 the joint associated with L4 nerve? If RF is done on the L4 nerve, how many needle injections is that exactly.  Any help would be appreciated. Thanks!!


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## dwaldman (Jul 2, 2014)

The joints that are be treated are L4-L5 and L5-S1. Since radiofrequency ablation procedure are per facet joint. Then you would have to report 64635 64636.

L3,L4 medial branches would innervate the L4-L5 facet joint.
L3 medial branch would be blocked at L4 anatomical target site.
L4 medial branch would be blocked at L5 anatomical site.
L5 dorsal ramus would be blocked at the sacral ala.
The additional block I believe would represent the S1 communicating branch that would be considering it  innervates L5-S1. It would be included in the L5-S1 level since RFA procedures of the facet joint nerves are reported per facet level. And the final level in the lumbar region is L5-S1.

Since there the facet joint receives dual innervation. From the medial branch at that level and from the level above you would the below chart of medial branch to facet joint relation

T11, T12 medial branches would innervate the T12-L1 Facet joint
T12, L1 medial branches would innervate L1-L2 Facet Joint
L1, L2 would innervate L2-L3 Facet joint
L2, L3 would.... L3-L4
L3,L4 would....L4-L5
L4, L5 would....L5-S1

So medial branches from L2-L5 (4 separate needles unilaterally) ((or L2-S1)) would be the three level block of the lower lumbar levels L3-4, L4-5, L5-S1

Below is from AMA CPT Assistant 2004

September 2004 page 1

The Facets of Paravertebral Facet Joint Procedures 


There are four facet joints associated with each single vertebra in the spine below the level of C2 and above the level of S1. For example, at the L4 vertebral level, there is an L3-L4 facet joint at the upper end and also an L4-L5 facet joint at the inferior end. 

Generally, each facet joint has dual innervation: one from the dorsal rami at the same level and one from the level above (eg, the L4-L5 lumbar facet joint is innervated by the medial branches of the dorsal rami from L3 and L4). Multiple injection levels are frequently performed when treating neck and upper back pain, as it is often difficult to isolate the exact joint level and two to three level injections may be performed at one sitting. Therefore, depending on the involved pathology, multiple-level facet joint and facet joint nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient. 

Below is from AMA CPT Assistant 2010

August 2010 page 12

Surgery: Nervous System, 64490, 64491, 64492 (Q&A) 

Question: Lumbar medial branch blocks were performed on the right at L3, L4, and L5. Would codes 64490, 64491, and 64492 be reported because three different levels were injected? 

Answer: No. The L3, L4, and L5 medial branch nerves innervate the L4-L5 and L5-S1 facet joints. Therefore, code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level, is reported for the first joint injected or blocked (L4-L5). Code 64493 is reported for a single or initial level treated. Add-on code 64494, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure), is reported for the second joint or level injected or blocked (L5-S1). In this specific instance only, CPT codes 64493 and 64494 should be used, provided the injections were performed in the lumbar spine with fluoroscopic (or CT) guidance, as required to use codes 64490-64495. 

To further clarify, add-on code 64495, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure), is reported only once per day for injections at the third and any additional lumbar or sacral level(s) treated (which does not apply to this case). Codes 64494 and 64495 should only be used in conjunction with code 64493. 

CPT codes 64490-64492 are reported in the same way for cervical-thoracic facet injections or blocks. In addition, add-on codes 64492, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) and 64495 are reported once per day as a singular line item irrespective of the number of spinal levels treated.


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## dwaldman (Jul 2, 2014)

I also provided information regarding SI Joint destruction. Again if this is for treatment of facet joints or nerves that innervate the facet joints, you can only report per facet level, SA-S1 would not be reported separately. As seen below, reporting for the lateral branches that innervate the SI Joint fall under separate coding and technique----individually nerve destruction for nerves that innervate the SI joint would be 64640. The reason I point this out, is if you are reporting treatment of the facet/facet nerve origin of pain you are only reporting per facet level.

Below is from AMA CPT Assistant Dec 2009

Procedurally, the work of the described SI joint destruction differs from that described by code 64622, Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level. Code 64622 may be reported for L5-S1 rhizotomy (nerve destruction since this joint lies between two spinal segments for which the anatomy and procedural work at L5-S1 is similar to that at other spinal segments (eg, L4-5). 

To differentiate between the work when performing sacral nerve destruction of S1, S2, S3, and S4, each individually separate peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by by neurolytic agent; other peripheral nerve or branch. In this instance, code 64640 is reported four times. It is suggested that Modifier 59, Distinct Procedural Service, be appended as well.


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## dwaldman (Jul 4, 2014)

Since I mention coding for SI denervation. I did want to include something that recently I saw thru the AMA CPT Network. This potentially could be published in the July AMA CPT Assistant and brought in to question how does this effect previous coding guidance with 64640

Date: 06/16/2014 

Surgery 

Nervous System 

Question 

What is the appropriate code to report a radiofrequency sacroiliac joint ablation? 

Answer 

There is no specific CPT code that accurately describes this service. Therefore, the unlisted code 64999, Unlisted procedure, nervous system, should be reported. When reporting an unlisted code to describe a procedure or service, it may be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, and the need for the procedure, as well as the time, effort, and equipment necessary to provide the service.


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## kseeg23 (Jul 7, 2014)

You are so helpful! Thank you!


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