# Dorsal Primary Ramus Injection



## NESmith (Oct 28, 2011)

Please help. Provider did:
Lt sacroiliac injection under fluoroscopic visualization
Lt L5, S1, S2 and S3 dorasal primary ramus injection under fluoroscopic visualization
Procedure: A timeout was performed neatly prior to the procedure. The surgical site was confirmed by the anesthesiologist, operative physician, and circulating or personnel, and the patient.
With the patient having had an intravenous started and all routine monitoring intact to include blood pressure and continuous pulse oximetry, patient was placed in the prone position. Sterile meticulous prep of the entire left sacroiliac area was performed using Betadine x 3 and a sterile draping was placed. 
A #22 gauge 3-1/2 spinal needle was then inserted into the inferior pole of the left sacroiliac joint and advanced to the mid joint position. This was confirmed with oblique and lateral fluoroscopic imaging. After negative aspiration, 0.5 cc of optirary non-ionic contrast was injected in the performance of a left SI joint arthrogram to ensure adquate spread of contrast beneath the joint capaule within the joint.
Ther was no vascular run off. Contrast spread beneath the joint capsule and was seen along the posterior border of the joint. For the purpose of interpretation and diagnosis, hard film copies were taken. There were no obvious bony abnormalities. A solution was then prepared containing 7 cc 0.25% bupivicaine, 12mg celestone soluspan and 2cc of preservative free normal saline. 3-4cc of the premixed solution was injected into the left joint. The needle was removed. In order to ensure dense joint blockage for diagnostic purposes the paravertebral facet nerves innervating the joints were anesthetized. A #25 guage 3-1/2 inch needle was placed at the left sacral ala and the 10 o'clock position of the S1, S2 and S3 dorsal foramen. Specifically targeting the left L5, S1, S2 and S3 medical branch nerves.  After negative aspiration, 0.-0.75 cc of the pre-mixed solution was injected at each level.
Hard film copies were made documenting needle placement and the needles were removed. Allinjection sites were sterilely dressed.
The patient tolerated the procedure well and was taken to the recovery room in stable condition with no complaints and neurologic exam was unchanged. After one-half hour the patient was evaluated with respect to pain response. The patient had a preoperative pain score of 8 and postoperative pain score of 8 on a numerical pain scale. The patient was given explicit instructions for followup. pending the residual benefits of this injection we will proceed with the treatment plan accordingly.

CPT codes billed:27096-LT
                         77003
                         64450-59LT
                         64450-7659LT
                         64450-7659LT
                         64450-7659LT
                         J0702
Commerical insurance denying for documentation does not support the 64450. I am not sure that these are the correct codes. Please give me your opinion and if they are correct, why would they be denied. Thanks as always for the help


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## dwaldman (Oct 28, 2011)

I think without information from the AMA CPT Assistant on your direct question there are certain things that have to be pieced together.

One thing that I noticed is a common rule with codes 64490-64495 is that if you are performing an intraarticular block and also blocking the medial branches of that level you only report for that level once, with that in mind, I would use that concept with the blocking of the lateral branches of the posterior primary rami at S1–S3, and the L5 dorsal ramus (L5DR). with intraarticular SI Joint injection. I personally wouldn't also separately report 27096 if you are billing 64450 x 4 for the L5 w/S1 thru S3 lateral branches that are innervating the joint.

Below is from CPT Assistant December 2009 where they give an example of a neurolytic block--- using the 64450 companion code-- 64640, as a appropriate to report for this type of individual nerve destruction treatment. If they don't accept this comparison concept might need to use an unlisted code, with the bundling of 77003 into 27096 descriptor in 2012 and the bundling into 64633, I would potentially forgo reporting 77003 if you are going to try to rebill or bill in the future.

I would bill as 
64450-LT
64450-51 LT ( x 3)
additional note 
L5 with S1 thru S3 Lateral branch injections

CPT Assitant
"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."


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