# MBB L3,L4,L5,S1 64493 64494 AND 64495 OR 64493/64494 only?



## KAT_G (Oct 30, 2017)

Hello,

I am wondering if anyone can give clarification on whether MBB performed on L3, L4, L5, and S1 (on the sacral ala) is coded as 64493 64494 and 64495 or only 64493 and 64494? I am getting conflicting info stating it is for L4/L5, L5/S1 and S1/S2 facet joints and another stating it only involves the L4/L5,and L5/S1. The op report makes no mention of facet joints only that MBB was performed on the L3,L4,LT, and S1 nerves. I need some solid references for the S1 involvement and whether it entails an additional facet joint. 

If anyone can recommend an anatomy sheet showing the medial branch targets and the facet joints involved that would be great too!

Thanks in advance!


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## dwaldman (Oct 30, 2017)

The S1 branch if it is believed to be contributing to the L5-S1 joint would be 100% included for the level at L5-S1. The code is reported for facet joint or nerves innervating the facet joint level. So if L4, L5, S1 are blocked to treat the L5-S1 level, then this is not involving S1-S2, You don't want to confuse lateral branches such as a block at L5, S1, S2, S3 that innervate the SI joint with a facet block

Below is from a chart from a past webinar from Marvel Hammer, RN, BS, CPC, CCS-P, ACS-PM, CPCO. & AMA CPT Assistant article as resources:




T12, L1 Medial Branches innervate L1-2 Facet joint
L1, L2 Medial Branches innervate L2-L3 Facet joint
L2, L3 Medial Branches innervate L3-L4 Facet joint
L3,L4 Medial Branches innervate L4-L5 Facet Joint
L4, L5 Medial Branches innervate L5-S1 Facet Joint
+ If it is considered the S1 branch is contributing to the L5-S1 facet joint, this would be included in L5-S1 level.

______________________________________________________________________________________________
AMA CPT Assistant 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.

__________________________________________

AMA CPT Assistant December 2009 page 11

Bonus Feature:Surgery: Nervous System

Question: Should code 64640 x 4 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 IIIâ„¢ 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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## KAT_G (Nov 1, 2017)

Thank you so much! This is really helpful for me. I truly appreciate it! 
~Katherine


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## cmbradd (Dec 1, 2017)

*Another question for you....*

Great thread, glad I found it. If I am coding Dorsal Ramus Sensory Nerve Block, L5-S4, Would I code the first level L5-S1 64493 & then 3 units of 64450 for the S2, S3 & S4 nerves?


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