# Genicular Neurotomy



## alysonrs (Mar 19, 2014)

Does anyone know the appropriate cpt for a Genicular Neurotomy.  The only thing I can come up with is 64999. This is a Cooled RF procedure on 3 nerves.

Any help would be appreciated.

thanks!


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## dwaldman (Mar 19, 2014)

"....articular nerve branches (genicular nerves) for treating knee joint pain due to chronic OA [Choi et al. 2011]. The genicular complex include branches of the femoral, common peroneal, saphenous, tibial, and obturator nerves feeding into the knee joint."

http://updates.pain-topics.org/2011/06/radiofrequency-relieves-chronic-oa-pain.html

Description: The Baylis Medical Co. Inc., which developed the Pain Management SInergy System, a cooled RFD system, was acquired by Kimberly-Clark Worldwide Inc. in 2009 (Kimberly-Clark Corp., 2009). The cooled RF energy device generates heat by radio waves, and is indicated for creating RFD lesions in nerve tissue. The radio waves are delivered to the targeted nerves via needles inserted through the skin above the spine. Sterile water pumped through the device circulates and cools the RF probe. Imaging scans are used to ensure safe and correct placement of the needles. In addition, stimulation of the nerves may be used to identify the location of the needle tip. Once proper placement is confirmed by electrostimulation or fluoroscopy, local anesthetic is injected to minimize the patient's discomfort, and the tip of the needle then heats the surrounding tissue (Kimberly-Clark Worldwide Inc., 2010). This procedure is repeated several times along the surface of the SI joint. In most cases, the procedure is relatively painless; patients may report a mild ache or pulsating feeling in the area during lesioning (Richeimer and Spinasanta, 2010). Through the use of the internally cooled RF probes, the tissue temperature immediately adjacent to the cooled electrode is maintained at 60?C, while the target tissue is heated to 75?C to 80?C, resulting in a lesion diameter ranging from 8 to 10 mm (millimeters). The main advantages of cooled-tip probes are the larger heating distance (up to 3 cm [centimeters] from the active tip), and greater depth of lesioning compared with conventional RFD, which creates lesions ranging from 3 to 4 mm in diameter. The electrodes are inserted at least 5 mm from the foramen to ensure that the temperature within the foramen does not exceed 45?C. An additional advantage of cooled RFD is that the needles are placed using a perpendicular rather than parallel trajectory, which is technically easier and causes less tissue trauma (Cohen et al., 2009; Gupta, 2010).

Above was some other information I found on cooled radiofrequency probes. I guess like you stated it could fall under 64999. I didn't know if 64640 could be used instead.


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## hgolfos (Mar 20, 2014)

My understanding of cooled RF is that the appropriate code is 64999.  64640 states destruction, but the temperatures used in cooled RF aren't high enough to permanently destroy the nerve.  Also, at the beginning of the section on nerve destruction in CPT the following is stated: 

"Do not report a code labeled as destruction when using therapies that are not destructive (eg. pulsed radiofrequency), use 64999"


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## alysonrs (Mar 20, 2014)

Thank you for the posts and the 64999 is what I thought I was going to have to use.  

Thanks!


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## dwaldman (Mar 22, 2014)

http://www.kchealthcare.com/products/pain-management/chronic-pain-solutions/genicular-neurotomy.aspx

At the above link, they have demonstration of the 3 probe technique for Cooled RF for Genicular Neurotomy. They describe in the demonstration that the temperature is at 63 degree Celsius. They are stating the difference between standard RF from cooled is the lesion size that can be created and the effect of the adjacent tissue.


Below United Health Care for example uses the above 60 degree benchmark for meeting the definition of "destruction."

Thermal radiofrequency ablation of facet joint nerves is proven for chronic cervical, thoracic and lumbar pain when confirmed by:  Temperature 60 degrees Celsius or more  Duration of ablation 40 - 90 seconds  Positive response to medial branch block injection at the side and level of the proposed ablation and  Confirmation of needle placement by fluoroscopic guided imaging


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