# Sacroiliac Radiofrequency Lesioning



## Melissa Harris CPC (Feb 4, 2014)

I am new to Pain Management and need some help coding the following:

DESCRIPTION OF PROCEDURE:  With written informed consent obtained, risk and benefits are discussed including but not limited to infection, bone, nerve and joint damage, spinal cord damage and paralysis.  Per patient request, the patient was then administered 2 mL of 2 mg/2 mL midazolam IM by the nurse.  The patient is then brought to the operating room and with appropriate monitors in place the patient is placed prone on the fluoroscopic operating room table.  The area of the Left  low back is prepped and draped in  sterile fashion. Under direct fluoroscopic guidance, the sacroiliac joint is visualized.  A skin wheal is raised over the joint using 1 mL of 1% Lidocaine. Another 2 mL's is used to infiltrate subcutaneous tissue at each level.  Then one 20 gauge 15 cm RF needle with a 5 mm active tip is advanced through the skin wheal and directed toward the inferior aspect of the posterior SI joint. Once bone is contacted, and after careful aspiration reveals no blood, a mixture of 4 mL 0.25% Marcaine and 1 mL of 40mg/mL Kenalog 5 mL of 1% Lidocaine was injected thru the needle before radiofrequency lesioning was begun at 80 degrees for 60 seconds.  This is repeated three more times moving up the joint, lesioning at four levels .  Once this was completed, the needle was removed, puncture wound was dressed.  The patient tolerated the procedure well. The patient was removed to the recovery area in stable condition.

The doctor wants to bill 64640 (and this has been the rule) but in my research I see that 64999 may be more appropriate.  Can someone please clarify for me?

Thank you


Melissa


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## dwaldman (Feb 5, 2014)

The below article references individual nerve destruction of nerves that are individually treated versus a probe that can treated the targeted areas simultaneously which they suggest 64999 for this type of treatment. This is found in the second article from 2009 from AMA CPT Assistant. From 2012 they also referenced the use of 64640 for appropriate reporting for this procedure involving individually treated nerves.  You could indicate to the physician to make sure to list the name of the nerves treated to support the separate levels being billed.
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 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 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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## Melissa Harris CPC (Feb 24, 2014)

Thank you.  I have another scenario where lesioning was done at 7 levels.  So if the SI lesioning was done at 7 levels I would report 64640 7 times with 59 on latter 6??


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