# Cpt 64636



## lcole7465 (Feb 14, 2017)

I have a pain doctor that performed an RFA on the L5-S1 and S1, S2, S3. Which I know would be the 64635, 64636. However, on the 2nd & 3rd  levels, the procedure wasn't completed. It says it was attempted but was unable to perform (no documentation as to why). Would the 64636 be billed with the 53 modifer? The provider did not mark this for coding.


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## PIKAPINK (Feb 16, 2017)

*cpt 64636*

query the doctor for additional information as to why he was not able to perform the injection, he would have to amend the record and then you can bill with the additional codes. and mod -53


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## dwaldman (Feb 16, 2017)

1. If a procedure is completed but other planned procedures are not carried out, you only report the completed procedure. 53 modifier is only used when their is no completed procedures but the procedure was started and the reason why it was discontinued is formally documented with the portion of procedure completed described that was attempted.

2. When you describe L5-S1, S1, S2, S3, you need to look at the indication for that procedure. You need to query the physician and ask if this procedure is for the lateral branches L5-S3 that innervate the SI joints. So this would be potentially 64640 per individual nerve destruction if it is non-pulsed or 64999 if it is pulsed or using the simplicity type probe where simultaneous treatment is carried out. As seen below from AMA CPT Assistant who describes the guidance for this coding which references L5, S1, S2, S3 for the lateral branch nerves that innervate the SI joint instead of the medial branches that innervate the facet joints under 6463X:

AMA CPT Assistant June 2012
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 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
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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