# S1, S2 & S2 radiofrequency



## BFAITHFUL

I have a report which states doc did S1, S2 & S3 radiofrequency,  I have a CPT Assist. which states CPT 64999 should be used if there was only one probe used to destroy each.. but use 64640x3 if each was destroyed individually with more than one probe.   what do you guys think?

Using an OEC 9800 fluoroscope, inferomedial aspect of the rigthg S1 joint was identified with caudal tilt and lateral oblique.  the right sacroiliac region was prepped and draped in sterile fashion with betadine.  after anesthetizing the skin with 1% lidocaine, a 10mm sharp curved tip 22 gauge RF cannula was passed and was advanced towards the lower aspect of the infero medial right sacroiliac joint.  the impedance was a range from 150 ohms to 180 ohms and the cannula was close to the medial aspect of the joint for the S3 median branch which was then lesioned at 80 degrees for 1 minute and 30 seconds.  after than, the cannula was advanced along the medial aspect of the right S1 joint to the mid of the lower one third of the joint for the S2 nerve root and similiarly for the S1 median branch.  the upper part of the inferomedial aspect of the right S1 joint was lesioned at 80 degrees each for one minute and 30 seconds.  the cannula was then removed.  prior to the removal 2cc of 1% lidocaine and 40mg of depomedrol were injected along the rigth S1 joint.  

thanks


----------



## Walker22

I work in a pain management clinic and we use 64640 for Sacral Nerve Ablation. Be aware that some payers consider this procedure "experimental".....


----------



## dwaldman

With the procedure note you provided I think that it displays the individual nerve destruction procedures which this part of the article would apply

"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."

Whereas if he would of placed a probe that has mutliple contacts and these contacts create lesions all at one time and each nerve is not treated individually at separate times then this part of the article that suggests 64999 would apply:

"the three independent, active contacts were positioned adjacent to the S1, S2, S3, and S4 lateral branch innervation pathways.... "Lesioning" was then carried out "


----------



## BFAITHFUL

thank you.  That's what I thought but wanted to make sure because only one cannula was used.


----------



## NESmith

I find your responses to be very interesting in the use of the CPT code 64640 The reason I say this is because Medicare LCD states that the use of the CPT code 64640 is used for Destruction by neurolytic agent;interdigital nerve of the foot-Morton's Neuroma. The reason why i am asking is because i have a provider who did RFAs of the left L4, L5, S1, S2, S3 and SA and he is billing 64622 x 1 and 64623 x 4. One of my other provider states this is incorrect and that he should be billing 64640 for S1, S2 & S3. Medicare is stating no that the ICD-9 will not support medical necessity. Please help me with this I am new to Pain Management and am trying to understand which is right and which is wrong. Thanks


----------



## dwaldman

"The sacroiliac (SI) joint and sacral anatomy differs in that it is comprised of spine bone and pelvic bone wherein the exact innervation of the SI joint occurring more from contri-buting branches at adjoining nerve levels. Procedurally, the work of the described SI joint destruction differs from that described by code 64622, Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level. Code 64622 may be reported for L5-S1 rhizotomy (nerve destruction since this joint lies between two spinal segments for which the anatomy and procedural work at L5-S1 is similar to that at other spinal segments (eg, L4-5). "

As you can see above, the AMA covered this in their CPT Assistant article. This gives you direction that below L5-S1 you would no longer have paravertebral facet joint nerves (medial branches (rami medialis) of the primary dorsal ramus) innervating the final facet joint at L5-S1. S1 innervations along with S2 S3 would most likely be the lateral branches branches that the physician is targeting. At the practice I work at SI Joint dysfunction which we use 739.4would be billed with 64640 and typically facet arthropathy 721.3 would be the primary and billed as such 

64622
64623
64640 x3 additional note on the claim RF Procedure performed at S1 S2 S3
77003

721.3 
739.4


----------



## jmistry

• i would code; if op report which states doc did S1, S2 & S3 radiofrequency ablation of sacral nerve for each was destroyed individually wiht more than one probe, i would use 64040 X 3 

• if there was only one probe used to destroy each.. use 64999

• Destruction of the sacral nerves via placement of a single RF probe midway between the lateral border of the sacral foraminal openings and the medial border of the SI joint. The single RF probe has multiple active electrodes. Code with 64999 (per CPT Assistant, Dec. 2009) because the technique and physician work are much different from the multiple separate destructions


----------

