# Help needed coding pain management injection-op report included



## MMAYCOCK

We are having a bit of confusion on how to code the following: Can someone help with this? I would like to know how it should be coded in both the physician office and the ambulatory surgery setting if possible. Thank you!
OPERATIVE REPORT:
Facet joint intra-articular injection at (L3-4, L4-5 and L5-S1 levels bilaterally), along with associated medial branch blocks After risks and benefits were reviewed, consent was obtained. The patient was taken back to our surgical suite and laid in the prone position. The mid back was sterilely prepped and draped in a typical fashion. The vitals were monitored throughout the entire procedure. Under flouroscopy, strict aseptic conditions, local anesthesia and standard protocols, mid back over the maximum axial tenderness is identified and coorelated with imaging study and levels of pain producing facet joint were identified , and selected lumbar facet joints were injected at (L3-4, L4-5 and L5-S1 levels bilaterally) is performed with (10 mg) of Methylprednisone along with 2cc of 1% Lidocaine at each of these levels. During injection of the medication patient's axial pain appeard to be reproduced. (Isouve-200, contrast dye was used to localize the intra-articular joint and to make sure that there is no spread of the medication intra-vascularly or intraduraly). Patient tolerated the procedure well.

It was coded with only two levels, but I believe it should be three. Our physician went to a seminar and was told to always subtract a level. Thank you!!!!
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## lwilkins

*MBB blocks*

At our pain management conference we were given a chart that L3-4 would be one level of medial branch innervation and L4-S1 would be an additional level of innervation for a total of 2 levels (64475 x1 and 64476 x1). Hope this helps. I believe that Marvel Hammer had this information on her website.


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## Walker22

lwilkins said:


> At our pain management conference we were given a chart that L3-4 would be one level of medial branch innervation and L4-S1 would be an additional level of innervation for a total of 2 levels (64475 x1 and 64476 x1). Hope this helps. I believe that Marvel Hammer had this information on her website.



This is incorrect. It takes 2 nerves to innervate 1 spinal level. Therefore in order to get one unit of 64475, you must do a medial branch block on L3L4 and L4L5. If you go on and do L5S1 as well, now you have 2 levels. There is an article in a recent Coding Edge concerning this, but I don't remember which one.


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## MMAYCOCK

*marvel hammer chart*

Can you give me her website address? I tried to google it but couldn't find MJH consulting. Also, does that mean that the C4-C5 is not considered a level?

Thanks


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## Walker22

MMAYCOCK said:


> Can you give me her website address? I tried to google it but couldn't find MJH consulting. Also, does that mean that the C4-C5 is not considered a level?
> 
> Thanks



C4-C5 is a _space between levels_. C4 is one level and c5 is a different level. In order to perform a medial branch block on the C4 level, you would inject the nerve at C3-C4 and the nerve at C4-C5. It takes 2 nerves to innervate one spinal level, one above and one below.

I am not familiar with this Hamel person and don't know anything about her web address, sorry. Read the Pain Management article in the March 2008 Coding Edge for more info on this.


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## marvelh

Facet joint injections can be performed either intra-articularly, i.e. the needle in inserted into the facet joint itself OR by injecting the paravertebral facet joint nerves (medial branches) that provide sensory innervation from the joint.  Since the code description includes both facet joint and facet joint nerve, providers and coders have had much confusion as to the compliant coding for injections.  

If you have access to old issues of the CPT Assistant, there is a fabulous article in the September 2004 issue that explains it in great detail.  In summary of the article, coding for facet joint injections is based on spinal level and not necessarily the quantity of needles inserted.  For example, if a physician inserts a needle into the right L3-L4 facet joint OR injects both the right L2 and L3 facet joint nerves (medial branches), the coding would be the same - 64475.  Each facet joint has sensory innervation from two facet joint nerves so in order to block the facet joint level, the provider must inject both nerves.

If a provider injects both intra-articularly into the facet joint AND blocks the medial branches that innervate the same joint, this is still coded as a single facet joint level.

From your op note, it reads that your physician injected both the facet joints (Facet joint intra-articular injection at L3-L4, L4-L5 and L5-S1 levels bilaterally) along with the associated medial branch blocks, (i.e. L1 medial branch at the L2 vertebrae, L2 medial branch at the L3 vertebrae, L3 medial branch at the L4 vertebrae, L4 medial branch at the L5 vertebrae and L5 dorsal ramus at the sacral ala) for a total of 3 spinal levels bilaterally blocked.  This would be coded as:
64475 - 50 x 1
64476 - 50 x 2

The subtract one (or n - 1 with n = the total number of needles) concept that your physician is thinking about refers to when physicians only inject the facet joint nerves, in that it takes 2 medial branches to block a single facet joint level (2 - 1 or 1 code) likewise it takes 3 medial branches to block two facet joint levels (3 - 1 or 2 codes), etc.  This doesn't apply when the physician is injecting the facet joint itself.  

My e-mail is marvelh@aol.com if you or your physician has questions.  Again, not an easy concept and from what I understand we should expect changes coming in 2010! :>(


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## marvelh

As for C4-C5, it is considered a spinal level with both a right and left facet joint between the C4 and C5 vertebrae.  

Just like in my previous post, your provider could insert a needle into the unilateral C4-C5 facet joint and it would be coded with 1 code 64470 and 1 unit of service

OR 

your provider could block both the C4 medial branch at the C4 vertebrae AND the C5 medial branch at the C5 vertebrae, in effect blocking a single facet joint spinal level (C4-C5) which would be coded with 1 code 64470 and 1 unit of service

Just when we thought we understood it...there is a change in nomenclature between the facet joints and corresponding facet joint nerves due to there is a C8 spinal nerve but no corresponding C8 vertebrae.  So the C4 and C5 facet joint nerves provide innervation to the C4-C5 facet joint level whereas in the thoracic region, the T3 and T4 facet joint nerves provide innervation to the T4-T5 facet joint spinal level just like the L3 and L4 facet joint nerves provide innervation to the L4-L5 facet joint spinal level.   Physicians vary in how they document these injections, some refer to the facet joint nerve itself (L3 and L4 medial branches), some refer to the facet joint spinal level (L4-L5 facet joint) and some refer to the needle placement at the individual vertebrae (needles inserted at the intersection of the transverse process and superior articular process of the L4 and L5 vertebrae).

Here is a link for a good illustration of the lumbar facet joint nerves in relationship to the facet joints: http://www.jkns.or.kr/fulltext/fig/0042006144f1.jpg


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## Walker22

marvelh said:


> Facet joint injections can be performed either intra-articularly, i.e. the needle in inserted into the facet joint itself OR by injecting the paravertebral facet joint nerves (medial branches) that provide sensory innervation from the joint.  Since the code description includes both facet joint and facet joint nerve, providers and coders have had much confusion as to the compliant coding for injections.
> 
> If you have access to old issues of the CPT Assistant, there is a fabulous article in the September 2004 issue that explains it in great detail.  In summary of the article, coding for facet joint injections is based on spinal level and not necessarily the quantity of needles inserted.  For example, if a physician inserts a needle into the right L3-L4 facet joint OR injects both the right L2 and L3 facet joint nerves (medial branches), the coding would be the same - 64475.  Each facet joint has sensory innervation from two facet joint nerves so in order to block the facet joint level, the provider must inject both nerves.
> 
> If a provider injects both intra-articularly into the facet joint AND blocks the medial branches that innervate the same joint, this is still coded as a single facet joint level.
> 
> From your op note, it reads that your physician injected both the facet joints (Facet joint intra-articular injection at L3-L4, L4-L5 and L5-S1 levels bilaterally) along with the associated medial branch blocks, (i.e. L1 medial branch at the L2 vertebrae, L2 medial branch at the L3 vertebrae, L3 medial branch at the L4 vertebrae, L4 medial branch at the L5 vertebrae and L5 dorsal ramus at the sacral ala) for a total of 3 spinal levels bilaterally blocked.  This would be coded as:
> 64475 - 50 x 1
> 64476 - 50 x 2
> 
> The subtract one (or n - 1 with n = the total number of needles) concept that your physician is thinking about refers to when physicians only inject the facet joint nerves, in that it takes 2 medial branches to block a single facet joint level (2 - 1 or 1 code) likewise it takes 3 medial branches to block two facet joint levels (3 - 1 or 2 codes), etc.  This doesn't apply when the physician is injecting the facet joint itself.
> 
> My e-mail is marvelh@aol.com if you or your physician has questions.  Again, not an easy concept and from what I understand we should expect changes coming in 2010! :>(



Actually it DOES apply when the physician is injecting the facet joint itself. In order to block 2 levels, you would have to inject the joint at L2L3, L3L4, and L4L5. This would provide a block at the L3 level and the L4 level.


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## marvelh

I respectfully disagree.  The facet joint is a joint between two vertebrae, i.e. C3-C4 or L3-L4 facet joint.  These joints can be injected either intra-articularly (1 injection to block 1 facet joint level) or blocking the medial branches that provide sensory innervation from the joint (2 injections to block 1 facet joint level).

When a physician inserts a single needle and injects into the facet joint itself, i.e. C3-C4, this would be coded as a single code - 64470.  Likewise if the provider injects the medial branches that provide innervation to the C3-C4 facet joint, i.e. injects both the C3 and C4 nerves, this also would be coded as a single code - 64470.

If the physician is blocking two levels, i.e. C3-C4 and C4-C5, he could insert needles directly into the 2 facet joints itself (intra-articular) [1 needle into the C3-C4 joint and 1 needle into the C4-C5 joint] which would be coded as 64470 x 1 and 64472 x 1 OR he could block the three medial branches (C3 medial branch at the C3 vertebrae, C4 medial branch at the C4 vertebrae and the C5 medial branch at the C5 vertebrae) that provide sensory innervation to the 2 facet joint levels C3-C4 and C4-C5.  This also would be coded as 64470 x 1 and 64472 x 1. The 3 medial branch injections would still be coded the same as the two intra-articular facet joint injections as only 2 facet joint spinal levels are blocked.

The following is an excerpt from the September 2004 CPT Assistant article:
"...It should be further emphasized that codes 64475, 64476, 64479, and 64480 refer to the injection of a facet joint either by injection into the joint with one needle puncture or by anesthetizing the two medial branch nerves that supply each joint (two needle punctures). For example, a left-sided L4-L5 intra-articular injection performed with a single needle puncture would be coded as 64475. Injection of the L3 and L4 medial branch nerves supplying the L4-L5 facet joint would also be coded as 64475, even though two separate injections are performed to effect the same result..."


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## RebeccaWoodward*

For what's it worth, I do agree with Marvel.

*"*From your op note, it reads that your physician injected both the facet joints (Facet joint intra-articular injection at L3-L4, L4-L5 and L5-S1 levels bilaterally) along with the associated medial branch blocks, (i.e. L1 medial branch at the L2 vertebrae, L2 medial branch at the L3 vertebrae, L3 medial branch at the L4 vertebrae, L4 medial branch at the L5 vertebrae and L5 dorsal ramus at the sacral ala) for a total of 3 spinal levels bilaterally blocked. This would be coded as:
64475 - 50 x 1
64476 - 50 x 2 *"*

The only difference is that some of my carriers require modifier 59 for the 2nd "add on" code
(64475-50, 64476-50, 64476-59-50)


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## lkeithcpc

My office manager, also the RT who assists with the procedures, wanted to know after reading everyone's responses, if it takes the 2 nerves to innervate one level, is that still the case with S1?


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