# RFA Sacroliliac Joint



## lcole7465 (Sep 7, 2018)

This one has me a little stumped.. My doctor wants to code: 64635, 64640 x 3; I'm seeing 64635/64636 x2; 

The op report reads:

Procedure: Left Radio-frequency ablation sacroiliac joint, specifically the dorsal  ramus of L5 and lateral branches of S1, S2 and S3

After obtaining consent, the patient was placed in prone position. I identified the sacral ala and the superior articular process of S1. I prepped the area with chlorhexdine in the usual sterile fashion technique. I used lidocaine 2% for skin infiltration. I advanced the needle until I had good position of the junction between the sacral ala and the superior articular process of the left S1. Then we identified the most median and superior part of the left SI joint. I advanced the needle towards the most lower and inferior portion of the SI joint on the left side until I had good position of the needle into the above level in the AP and lateral views. The following technique was used to confirm placement at the median branch nerves.

Sensory stimulation was applied to each level at 50Hz; parenthesis were noted below 0.6 micro-volts. Motor stimulation was applied at 2Hz with 1 millisecond duration. corresponding paraspinal muscle twitching without extremity movement was noted. Following this, the needle trocar was removed and a syringe was removed and a syringe containing 0.25% bupivicaine was attached. At each level, after syringe aspiration with no blood return, 1 mL of 0.25% bupivicaine was injected to anesthetize the median branch nerve and surrounding tissue. After completion of each nerve block, a lesion was created at that level with a temperature of 80 degrees Celsius for 90 seconds. All injected medications were preservative free. Sterile technique was use throughout the procedure.

Any insight would be greatly welcome!!!!


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## dwaldman (Sep 12, 2018)

Below from AMA CPT Assistant June 2012 describes L5, S1, S2, S3 as CPT 64640 being reported 4 times for radiofrequency ablation with individually separate nerve destruction. I think you would need to review with the physician that this the AMA stance on RF procedure for nerves innervating the SI joint which includes the L5 level. The issue is CPT 64635 code descriptor describes nerves innervating the facet joint. So the nerves targeted in the procedure at L5 are providing innervation in this case to the SI joint as the source of treatment it seems 64640 would be more accurate since the facet joint is not being treated and 64635 is for  facet joint nerve ablation.

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AMA CPT Assistant
June 2012 page 15

Frequently Asked Questions:Surgery: Nervous System

Question: May code 64640 be reported for each individual peripheral neurolytic nerve destruction procedure performed at the L5, S1, S2, and S3 nerves? 

Answer: Yes. When performing individually separate nerve destruction, each peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, for peripheral nerve root neurolytic blocks (destruction) of L5, S1, S2, and S3, code 64640 should be reported four times. The coder should append modifier 59, Distinct Procedural Service, to the second and subsequent listings of code 64640 to separately identify these procedures. 


___________________________________________


AMA CPT Assistant December 2009
Surgery: Nervous System
Question: Should code 64640 x4 be reported per lesion because it is a single percutaneous entry point or should the unlisted code 64999 be reported? What is the appropriate code to use
for radiofrequency (eg, Simplicity III™ Radiofrequency Probe) for sacroiliac (SI) joint nerve destruction from a single percutaneous entry site in the following procedure? 
The Simplicity III electrode was then advanced, maintaining continuous contact with the sacrum, on a cephalad and slightly lateral line, staying lateral to
the sacral foramen, medial to the sacroiliac joint, and ventral to the ilium, until contact with the sacral ala prevented further advancement. Appropriate positioning
was confirmed by changing the caudal/cephalad tilt of the C-arm to parallel the superior endplate of S1; and verifying once again that the entire length of the
Simplicity III electrode was advanced to the ipsilateral sacral ala and the three independent, active contacts were positioned adjacent to the S1, S2, S3, and S4
lateral branch innervation pathways…. “Lesioning” was then carried out using the Simplicity III preprogrammed protocol at 85 degrees centigrade for five minutes.
Karen Glancy, CCS-P

Answer: Since the documentation indicates insertion of a single electrode (having three contacts) at the sacroiliac (SI) joint “to lesion the lateral branches of S1, S2, S3,
and S4,” code 64999, Unlisted procedure, nervous system, is reported once. This “SI joint rhizotomy” would be reported once using the unlisted nervous system code 64999. The
sacroiliac (SI) joint and sacral anatomy differs in that it is comprised of spine bone and pelvic bone wherein the exact innervation of the SI joint occurring more from contributing
branches at adjoining nerve levels. 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). Therefore, the unlisted nervous system code 64999 would be reported once for SI joint or sacral rhizotomy (nerve
destruction). 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.  It is very important that the service performed matches accurately with the descripton in the CPT code. Therefore,
for this very reason, it is important to remember that a code that is “close” to the procedure performed is not selected in lieu of an unlisted code. There are some who
maintain that they are not allowed to use unlisted codes or that the use of the unlisted codes is undesirable. While the use of an unlisted procedure code does require a special report or documentation to describe the service, correct
coding demands that you use a code that is appropriate for the service being provided (ie, a code that most accurately represents the services rendered and performed)


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