# RFA of L5, S1, S2, S3



## celcano (May 5, 2015)

I know that the AMA has come out with guidance on how to bill a RFA of the L5, S1, S2 and S3.  However, I was curious how codes 64635/64636 are to used as they are for "lumbar or sacral".  Is there ever a time I would use 64635/64636 for a sacral RFA?


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## kacey (May 5, 2015)

64635 and 64636 would never be used for sacral RF.  You are correct in that there are guidelines on how to code L5 dorsal ramus, S1, S2, S3 ablations and they instruct you to code 64640 with four units of service.

I think I've bugged Marvel Hammer for confirmation on this procedure on more occasions than I'd like to admit


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## dwaldman (May 5, 2015)

CPT 64635 64636 are for destruction by radiofrequency of the facet joint nerves that innervate the facet joints.

These would be described as the medial branches that innervate the facet joint.

You might notice in the report that they are describing the lateral branches innervating the SI joint, since this is for treatment of the SI joint not the Facet joint, CPT 64635 64636 would not be appropriate.

Below is example of RF procedure of the nerves innervating the SI joint and you will se the description of lateral branch and there are published from AMA CPT Assistant that individually (separate) lesioning/ablation can be reported with CPT 64640. Check your carrier's policy and Medicare LCD, for example WPS Medicare J5 states this type of procedure is non-covered and they request 64999
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For blockade and lesioning of the L4 and L5 dorsal rami, 22-gauge SMK-C10 cannulae (Radionics, Burlington, MA) with 5-mm active tips were inserted parallel to the course of the nerve until bone was contacted just superior and medial to the junction between the superior border of the transverse and superior articular processes for procedures done at L4, and at the junction of the ala and articular process of the sacrum for L5 procedures, similar to previously published studies.14,15 Because it is not possible to discern electrostimulation between the various branches of the L4 primary dorsal ramus (it is the lateral branch that may innervate the sacroiliac joint), the targeted nerve at this level is referred to as the parent branch. At each level, placement of the electrode in close proximity to the nerve was confirmed using electrostimulation at 50 Hz, with concordant sensation achieved at 0.5 V or less. Before lesioning, the absence of leg contractions was verified with stimulation at 2 Hz up to 2 V. After satisfactory electrode placement, 0.5 ml lidocaine, 2%, was injected through each cannula to reduce thermal pain and ensure blinding. The radiofrequency probe was then reinserted, and a 90-s, 80?C lesion was made using a radiofrequency generator set to the lowest audible volume to blend in with ambient noise (Electrothermal 20S Spine System; Smith and Nephew, Andover, MA, or Radionics RF Lesion Generator System, model RFG-3C; Radionics, Valleylab, Boulder, CO).


For S1?S3 lateral branch procedures, 17-gauge, 75-mm cooled electrodes with 4-mm active tips (Baylis Medical, Montreal, Quebec, Canada) were inserted between 3 and 5 mm from the lateral border of the foramina at predesignated positions. For right-sided S1 and S2 procedures, these corresponded approximately to the 1:00, 3:00, and 5:30 positions on the face of a clock; on the left, the target sites were at 6:30, 9:00, and 11:00 (fig. 2). At S3, needles were placed at 1:30 and 4:30 on the right side and at 7:30 and 10:30 on the left side. In 10 patients in whom the S4 foramen was located level with or just below the inferior portion of the sacroiliac joint, one upper lesion was also done at S4. Sensory stimulation was performed at each level only for the first needle placement, revealing concordant sensation at 0.5 V or less. Before lesioning, 0.5 ml lidocaine, 2%, was administered per spinal level. To ensure that anesthetic spread to adjacent foramina did not impede sensory testing, electrodes were placed and stimulated at contiguous levels before denervation commenced. When the needles were properly positioned, monopolar electrodes were sequentially inserted into the cannulae, and 2.5-min lesions were made using a water-cooled radiofrequency heating system


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