# Mbb



## BeckyGK (Jan 31, 2012)

I would like to know on the MBB done with fluoroscopy, how you would code this scenerio for 2012.  I had some previous info from MHammer, but it is old.  Any articles referenced would be great also.  

RT & LT L4,5 facet median nerve branch block and L5 Dorsal Ramus nerve block ....
a 22 G 3.5 inch spinal needle with tip slightly bent was inserted under AP fluoro guidance to lay at the junction of the vertebral body and transverse process.  Needle was advanced & adjusted to lay on the desired position under oblique view using fluoro guidance.  One cc of bupivacaine 0.75% per level was injected and total of Triamcinolone 40 mg was divided equally on all levels Total needles used is 6 needles.


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## aaron.lucas (Jan 31, 2012)

I would say 64493-50 & 64494-50 for the MBB (they are bilateral right?), and then perhaps 64450 for the dorsal ramus, cause I cant find anything else that matches that, and 64450 says "other peripheral nerve or branch"?  although not sure if that's correct either because I dont know that the dorsal ramus nerve is peripheral or a branch.  But I'm confident about the MBB, and dont forget since 2010, no fluoro with the MBB.  hope this helps!


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## BeckyGK (Feb 2, 2012)

Sorry I should have put this in the information from MHammer:

For a period of time, some providers considered the L5-S1 facet joint to have innervation from 3 nerve branches rather than the standard two...
L4 medial branch that is injected at the L5 vertebral body
L5 dorsal ramus that is injected at the sacral ala
AND a communicating branch from the S1 spinal nerve.

Newer anatomic research has found that there isn't a communicating branch as once thought and many pain mangement providers now only inject the L4 medial branch and the L5 dorsal ramus to block the L5-S1 facet joint.

With that said, the provider is still only blocking 1 facet joint level - L5-S1 and as such would be reported as 64493

Also to say that I am looking for where she may have gotten the information from a book showing this or where.  I am telling Dr one code 64493 or 64493/50 if bilateral, but I am looking for more corroboration to show my doctor possibly newer for 2012 info would be great too.

I had also seen this:  

 06-07-2011, 10:28 AM 
theso13  
New	 	Join Date: Apr 2007
Posts: 7 


 MNBB and Dorsal ramus injections 
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Our doctor wants to bill for L4-5 median nerve branch block as well as for a L5 dorsal ramus procedure. Can both 64493 and 64494 be billed with these levels? 

  #2         
 06-08-2011, 07:55 PM 
dwaldman  
True Blue	 	Join Date: Apr 2007
Posts: 611 



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Below CPT Assistant references would support two facet levels in the lumbar region represented by 64493 as described by the L3,L4 medial branches that innervate the L4-L5 facet joint and 64494 for the L4 medial branch and L5 dorsal ramus innervating the L5-S1 facet joint.

August 2010 CPT ASSISTANT

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).

Additionally from September 2004 CPT ASSISTANT

"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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## aaron.lucas (Feb 3, 2012)

OH, ok, the way you listed it before made it look like two separate levels, but now it looks like one joint bilateral, plus the dorsal ramus, so now I'm thinking 64493-50, and then 64494 with no modifier?  From what the CPT assistant info says that seems to be how it should be coded.  as far as I know there weren't really any changes to the facet injection codes, so you should be safe using the 2010 assistant.


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## BeckyGK (Feb 13, 2012)

Yeah I know confusing.  I am going to a meeting that Marvel Hammer is going to speak at on this subject maybe she will have some newer references.  Thank you


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