# L5 Dorsal Ramus and S1,S2,S3 lateral branch block



## dhunter

Need some help coding the procedure below. The pain managment doctor would like to use the following CPT codes 64493, 27096, 99144, 77003 and then has a question mark next to 64450.

A 25 gauge spinal needle was advanced at the junction of the S1 superior articular process for the L5 dorsal ramus and lateral the S1, S2, S3 neuroforamens, near or at the sacroiliac joint. Isovue 200 contrast was thereafter injected to confrim placement and delivery of the injected solution to the appropriate target under real time fluoroscopy there was no evidence of intravascular spread. After negative aspiration 1cc 0.25% marcaine without epinephrine PF was thereafter slowly injected over each medial branch.

Thanks,
Dawn


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## dwaldman

A 25 gauge spinal needle was advanced at the junction of the S1 superior articular process for the L5 dorsal ramus -----(64493)

"lateral the S1, S2, S3 neuroforamens, near or at the sacroiliac joint."

"thereafter slowly injected over each medial branch."

See above medial or lateral for S1-S3


For 27096, for example WPS Medicare LCD for SI Joint blocks states:

" Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint, confirming accurate placement of the needle into the joint. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should only be reported when imaging confirmation of intra-articular needle positioning has been performed and should be billed with the applicable radiological and/or fluoroscopic procedure code......."

This is describing an intra-articular joint injection. They are not describing 27096 as injecting near the SI Joint or mentioning S1 S2 S3 neuroforamens

As seen below 

"A medial branch neurotomy affects the nerves carrying pain from the facet joints, and a lateral branch neurotomy affects nerves that carry pain from the sacroiliac joints"

http://www.spine-health.com/treatme...ncy-neurotomy-facet-and-sacroiliac-joint-pain

Lateral branch neurotomy as described as individually treatments has been suggested in CPT Assistant as be able to be billed as 64640

The corresponding non-neurolytic code would be 64450

 you can ask is this the lateral branches of S1 S2 S3
that were blocked and suggest

64493
64450 x 3

Since 77002 is bundle with 64450 and there is nothing published stating you can use 77003 with 64450 with type of procedure, I would be tempted to forgo billing the fluoro.


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