# Need help coding Bilateral Radiofrequency Ablation Injections



## ashleymamas

*I need some help coding Bilateral Radiofrequency Ablation Injections*

The op note I am coding is as follows: Lumbar selective Facet Medial Branch Radiofrequency under flouro on L3,L5, S1, L4 all bilaterally. 

I am having trouble coding these, can someone help... I think i am having a units issue, or maybe not sure how many levels, desperatley need some assistance as soon as possible


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## dwaldman

L2 medial branch blocked at L3 transverse process

L3 medial branch blocked at L4 transverse process

L4 medial branch blocked at L5 transverse process

L5 dorsal ramus blocked at the Sacral Ala

“At the L5 level, the transverse process is replaced by the sacral ala, and the L5 dorsal ramus arises from the spinal nerve just outside the L5-S1 intervertebral foramen, passing dorsally over the sacral ala in a groove formed by the junction of the ala with the root of the superior articular process of the sacrum. The medial branch arises as the nerve passes in this groove, and then wraps medially around the posterior aspect of the lumbosacral (L5-S1) zygapophyseal joint, terminating in the multifidus muscle.”

http://www.dcmsonline.org/jax-medicine/1998journals/october98/facetdenervation.htm



L2, L3 innervate the L3-L4 joint 64635

L3,L4 innervate the L4-L5 joint  64636

L4,L5 innervate the L5-S1 joint  64636

If performed bilaterally 50 modifier could be applied to each line. There is an element of trial and error on how certain carriers require the claim to be set for them to process without duplicate denials. Additional not on the claim can help.


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## dwaldman

I was interpreting on L3, L5..... as the anatomical location versus the medial branches. You would want to work with the physician to clarify does he indicate this as the anatomical location of the injection or the medial branches themselves.

If he is stating the treatment of L3, L5, L4, S1 as medial branches and not indicating these are anatomical locations of the procedures then 

L3, L4 (L3 at L4 antomical location, L4 at L5 anatomical location) 64635
L4,L5,S1 ( L4 at L5 anantomical location, L5 at Sacral ala, S1 communicating branch included) 64636


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## aaron.lucas

actually that's not correct, the new codes aren't based on levels anymore.  codes 64633-64636 are per joint, not level.  the change was made to eliminate confusion that was related to figuring out the levels once you get down to L4/L5/S1.  I think the units that are listed are correct, just that you're going by levels when it should be joints.  so it would be one for L3/L4, then L4/L5, and then L5/S1, so three units is correct (one initial plus 2 add-on), as would be the -50.


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## dyoungberg

Just a quick addition to the above.  In billing these new codes I've come across some information I can share.  If you're billing Medicaid or Worker's Comp, they don't accept the new codes so you must bill with the old codes of 64622-64627 with 77003.  If you're billing Tricare with the new codes, list 64636 or 64634 on one line and list the # of units instead of a line for each level, otherwise they will allow only one level and deny the other as a duplicate.


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## dwaldman

L2, L3 innervate the L3-L4 joint 64635

L3,L4 innervate the L4-L5 joint 64636

L4,L5 innervate the L5-S1 joint 64636

L3, L4 (L3 at L4 antomical location, L4 at L5 anatomical location) 64635
L4,L5,S1 ( L4 at L5 anantomical location, L5 at Sacral ala, S1 communicating branch included) 64636 

aaron.lucas,
the post I provided are per joint.


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## dyoungberg

*Medicare & new radiofrequency codes*

Is anyone having issues with Medicare paying for more than 1 level of lumbar or cervial radiofrequency?   I recently billed 64635,64636 & 64636.  Medicare paid for 64635 & one level of 64636, citing I needed a modifier on the 2nd level of 64636 to get paid for that 3rd injection.  Of course they won't offer up the modifier needed.  I've searched their website and LCD's and have come up with nothing related to this.


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## josephmglick

I would bill 64636 with units not on separate lines.  So 64635 - unit and 64636 - units.


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## mhstrauss

dyoungberg said:


> Is anyone having issues with Medicare paying for more than 1 level of lumbar or cervial radiofrequency?   I recently billed 64635,64636 & 64636.  Medicare paid for 64635 & one level of 64636, citing I needed a modifier on the 2nd level of 64636 to get paid for that 3rd injection.  Of course they won't offer up the modifier needed.  I've searched their website and LCD's and have come up with nothing related to this.



If this is the way it got denied:

64635
64636x2

The most likely (IMO) alternative would be:

64635
64636
64636-59

I know a lot of people are weary of using 59 with MAC's, but sometimes that is whats required.  Hope this helps!


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## ckkohler

It also depends on whether the RF is done bilaterally or unilaterally.  If you bill it with a modifier -50 to indicate bilateral, you can't have multiple units - in that case, I agree with Meagan .. you have to bill the 2nd 64636 w/modifier -59.


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## dwaldman

In regards to bilateral reporting for 64633-64636, I saw the below in the pain management article in AAPC Coding Edge April 2012, Page 19:

"For example, to describe radiofrequency ablation of the C3, C4, and
C5 medial branches, you would report 64633, 64634 because the
sensory innervation to two facet joint levels, C3-C4 and C4-C5, was
neurolysed. For bilateral L3-L4, L4-L5, and L5-S1 facet joint neurolysis
(i.e., L2, L3, and L4 medial branches and L5 dorsal ramus), correct
coding would be 64635-50, 64636-50 x 2 units of service (or, depending
on your payer, 64635-LT Left side, 64635-RT and 64636-
LT x 2, 64636-RT x 2)."


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## RCMCoding1

I got one example where provider has billed CPT 64635 with 1 unit & 64636 with 3 units,
Procedure performed on Left L2, L3, L4 and L5 4 Level Medial branch nerve.

I am confused, how should I bill,

I guess, 
64635 x1 LT
64636 x2 LT is correct.

I want to inform doctor about this. If any reference, that would be really helpful !!


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## dwaldman

RajeshG,

Below describes for dates of service 2012 and forward, radiofrequency ablation procedure of the facet joint nerves is reported per facet joint level. 

L2,L3---L3-L4
L3,L4---L4-L5
L4,L5---L5-S1

64635
64636 x 2

AMA CPT Changes 2012

"Prior to 2012, the unit of service used to report these procedures was a single nerve at a single vertebral level. However, two nerves innervate each facet joint, and there are two facet joints at each vertebral level. One or two facet joints at the same level potentially could be treated. As such, the vertebral level is of less significance than the number of facet joints treated, so using vertebral level as the unit of service did not adequately reflect the work performed. To address this issue, the unit of service is a single facet joint in new codes 64633, 64634, 64635, and 64636, rather than a vertebral level. If both facet joints at the same vertebral level are treated, then the parent code (64633 or 64635) should be reported with modifier 50 appended. It is important to note that the number of nerves injected for a single facet joint does not affect code selection. Therefore, the new codes indicate "nerve(s)" in the descriptors."


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