# need some direction



## TiffianyEdwards (Jan 13, 2015)

Need some help please:
We are billing 
64633 64634 64634-59 and 99144  

Planned Procedure: Radiofrequency ablation of the Right C4-5 C5-6, and C6-7  facet joints, C4,C5,C6,C7 medial branch nerves
Levels: Right C4, C5, C6 and C7  For the Right C4-5, C5-6 and C6-7 facet joints
The C4 and C5 medial branch nerves innervate the C4-5 facet joint  
The C5 and C6 medial branch nerves innervate the C5-6 facet joint
The C6 and C7 medial branch nerves innervate the C6-7 facet joint


Pre/Post-Procedure Diagnosis: 
1.  Cervical spondylosis   IR Paravertebral Facet Joint Neurolysis 1 Facet Cervical Thoracic Right  
  IR Paravertebral Facet Joint Neurolysis 1 Facet Cervical Thoracic Right  

Informed Consent:  The patient's condition and proposed procedures, risks, benefits and alternatives were discussed with the patient in detail.  All questions were answered in detail and the patient chose to proceed.   Informed consent was obtained.       
Time Out: A time out verifying correct patient, medical record number, allergies and surgical site was performed immediately prior to beginning the procedure.
IV: Peripheral IV access was obtained.  A 22g IV was placed in the patient's hand
.
Sedation: Versed 1 mg Fentanyl 50mcg
HPI: Ms. XXXXXXXX is a 53 y.o. female who presents with neck, upper back and shoulder pain.  Previous treatment has included Medial branch blocks Helped. The patient reports >50% benefit from these blocks.
Procedure Description: The patient was placed in the prone position and made comfortable on pillows.  Pulse oximetry and noninvasive blood pressure cuff were monitored throughout the case.   
The skin of the neck was prepped with ChloraPrep and draped in sterile fashion. C-arm fluoroscopy was used to obtain a AP view in order to facilitate a AP approach to the target points at the midpoint of the 2 vertices of the quadrangle of the articular pillars on lateral view and the midway between the superior and inferior articular surfaces of the vertebrae at the "waist" of the pillar in AP view. The skin puncture sites were anesthetized with 2 mL 1 % Lidocaine.  A 50 mm radiofrequency canula was used. The cannula was advanced advancement, at each level, using AP and lateral fluoroscopic guidance.  Final needled positioning was performed in the lateral fluoroscopic view and the cannulas were advanced to the target point. In the case of the third occipital nerve, two radiofrequency cannulas were placed slightly superior and inferior to the C2-3 facet joint in lateral view. Confirmed needle tip on bone.  Once all needles were considered to be in a satisfactory fluoroscopic position, sensory and motor stimulation was performed.  Sensory stimulation was performed at 50 hertz, and was considered positive if pain was reproduced in a concordant fashion at a voltage at less than 1 millivolts. With motor stimulation, the goal was to see the absence of radicular upper extremity motor twitching or pain at the voltage greater than three times the magnitude of the sensory threshold. Specific parameters are available for review in the chart. This was performed for all levels. After satisfactory sensory and motor stimulation was complete, 0.5mL of 2% Lidocaine was placed through each needle.  Lesioning was then performed at 80 degrees Celsius for 90 seconds at each level.  The patient tolerated the procedure well.  All needles were removed and Band-Aids were placed.
No immediate complications were observed.
C4: Sensory 1.6 Motor 3
C5: Sensory 1.2 Motor 2.0
C6: Sensory .5 Motor 1.5
C7; Sensory .7 Motor 1.5
Outcome: Patient's pain score was 7/10 before the procedure and 5/10 after the procedure. After meeting discharge criteria, the patient was discharged home with her escort/driver.  
Impression/Follow-Up: Ms. XXXXXXX will follow up in 4 week to decide on the longer-term effects of today's procedure and consider RFA of the left at that time.  She was instructed to call immediately if any of the following develops: new upper extremity neurologic symptoms, fever, worsening pain, headache, or any other symptoms


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## Amy Pritchett (Jan 14, 2015)

First,
Do you work for an anesthesia group or, do you work for a pain management physician? Also, was this performed in the office under MAC? I am sure that this procedure lasted longer than 30 minutes of time. Also, no -59 modifier should be placed on the second 64634 as the description states (each additional level). 
Can you please answer the above questions so I can make a better judgement on how to further help you?
Thank you


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## marvelh (Jan 24, 2015)

You will need to check with the physician as there is a "mismatch" between the procedure title and the procedure description.  In the procedure description,needle placement for third occipital nerve at C2-C3 is described " In the case of the third occipital nerve, two radiofrequency cannulas were placed slightly superior and inferior to the C2-3 facet joint in lateral view. Confirmed needle tip on bone."

Possibly this is a templated procedure note but should not code without clarification. 

IF the physician really only performed C4, C5, C6 & C7, then the coding would be 64633 -RT x 1 and 64634 -RT x 2.  Many Medicare contractors do  not want modifier 59 used to separate out duplicate line items, they request either  using the units of service field with one line item OR using modifier 76 on the second line item of the add-on code.  You will need to check if the payer is Medicare.  Additionally, the procedure note should be corrected to indicate that the 3rd occipital nerve was not RF ablated.

 Additionally billing for moderate sedation required documentation of intra-service time, which I don't see included in the procedure note.


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## TiffianyEdwards (Jan 26, 2015)

*response to question*

I work for a Pain Mangmt phys. It was performed at the hospital not in the office. They are scheduled as interventional radiology procedures.


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