# Coding my first RFA-Help please!



## Jinx75 (Sep 9, 2013)

Procedure: Radiofrequency lesioning od right L5 dorsal ramus
Radiofrequency lesioning of S1, S2, S3 lateral branches

Op note states "For medial branch radiofrequency lesioning a 150mm, 20 gauge (with 15mm active tip) curved radiofrequency needle was guided using oblique fluoroscopic views at the appropriate verterbral level to make boney contact with the inferior medial border of transverse process (junction of the superior articular process and transverse process).  For lateral branch radiofrequency lesioning a 150mm, 20 gauge (with 15mm active tip) curved radiofrequency needle was guided using oblique fluoroscopic views to make boney contact between the appropriate sacral foramen and the sacroiliac joint.  Lateral fluroscopic images were viewed.  Next sensory stimulation was obtained at each level at or below 1Hz up to 1 volt.  Then motor simulation at 2Hz up to 2 volts did not cause any radicular symptoms at each level. Continuous radiofrequency was then performed at 80 degrees C for 90 seconds.

The Dr is coding:

64635 
64636
64640 x3

Is this correct?  I am trying to understand how she is getting 5 levels?


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## KMCFADYEN (Sep 9, 2013)

I would ask for better documentation-levels not documented.


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## Jinx75 (Sep 10, 2013)

Wonderful, thank you for your response.


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## capricew (Sep 10, 2013)

the last i knew was that si joint RFA was to be coded as an unlisted code because it is different than the codes supplied by 64435, 66436

"Your first step toward correct coding is to verify
whether the physician performed the destruction within
the SI joint itself or to the nerves that innervate the SI
joint. Chances are, you'll be coding for procedures that
affect the surrounding nerves.
“The injections often are performed on nerves that
derive from the lateral branches of the S1-S3 dorsal rami,”
explains Myriam Nieves, CPC, ASC-PM, director of
coding and reimbursement for Axis Management and
Billing Services in Hollywood, Fla. “Therefore, the
provider's documentation will most probably state that
‘Motor stimulation was performed at the SIJ medial
branch nerves.'”
Not so fast: Many coders rely on codes 64622
(Destruction by neurolytic agent, paravertebral facet joint
nerve; lumbar or sacral, single level) or 64623 (… lumbar
or sacral, each additional level[List separately in
addition to code for primary procedure]) for these
injections, but that can be a mistake. Some basic
knowledge of anatomy helps to show why:
Reason 1: The paravertebral facet joint nerves don't
innervate the SI joint. Nieves believes that coders usually
get confused because the descriptors of 64622 and 64623
read “lumbar or sacral.” Coders who are not familiar with
anatomy might think this justifies an injection in the
sacroiliac joint.
Reason 2: There are no paravertebral facet joints
below the L5-S1 facet joint. Providers often perform
destruction of some branches that innervate the SI joint
(such as L5, S1, S2 and S3). These are not paravertebral
facet joint nerves, so coding it as such is incorrect.
Report RF More Accurately with 64640 or 64999
So, if 64622 and 64623 aren't accurate for reporting
RF of the nerves surrounding the SI joint, what's your best
option? Many coders tend to agree that you have two
viable alternatives, depending on the situation: 64640
(Destruction by neurolytic agent; other peripheral nerve
or branch) or an unlisted code, such as 64999 (Unlisted
procedure, nervous system). 
Your first step toward correct coding is to verify
whether the physician performed the destruction within
the SI joint itself or to the nerves that innervate the SI
joint. Chances are, you'll be coding for procedures that
affect the surrounding nerves.
“The injections often are performed on nerves that
derive from the lateral branches of the S1-S3 dorsal rami,”
explains Myriam Nieves, CPC, ASC-PM, director of
coding and reimbursement for Axis Management and
Billing Services in Hollywood, Fla. “Therefore, the
provider's documentation will most probably state that
‘Motor stimulation was performed at the SIJ medial
branch nerves.'”
Not so fast: Many coders rely on codes 64622
(Destruction by neurolytic agent, paravertebral facet joint
nerve; lumbar or sacral, single level) or 64623 (… lumbar
or sacral, each additional level[List separately in
addition to code for primary procedure]) for these
injections, but that can be a mistake. Some basic
knowledge of anatomy helps to show why:
Reason 1: The paravertebral facet joint nerves don't
innervate the SI joint. Nieves believes that coders usually
get confused because the descriptors of 64622 and 64623
read “lumbar or sacral.” Coders who are not familiar with
anatomy might think this justifies an injection in the
sacroiliac joint.
Reason 2: There are no paravertebral facet joints
below the L5-S1 facet joint. Providers often perform
destruction of some branches that innervate the SI joint
(such as L5, S1, S2 and S3). These are not paravertebral
facet joint nerves, so coding it as such is incorrect.
Report RF More Accurately with 64640 or 64999
So, if 64622 and 64623 aren't accurate for reporting
RF of the nerves surrounding the SI joint, what's your best
option? Many coders tend to agree that you have two
viable alternatives, depending on the situation: 64640
(Destruction by neurolytic agent; other peripheral nerve
or branch) or an unlisted code, such as 64999 (Unlisted
procedure, nervous system). 

clearly this article was written when the old codes 64626 and 64627 were still in use but i cannot find anything to state this has changed.

Good luck
"


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## dwaldman (Sep 10, 2013)

You need to indicate to the physician that each individual nerves treated need to be indicated in the note: Have an addendum be made or revised note if not past thirty days.

"For lateral branch radiofrequency lesioning a 150mm, 20 gauge (with 15mm active tip) curved radiofrequency needle was guided using oblique fluoroscopic views to make boney contact between the appropriate sacral foramen and the sacroiliac joint. Lateral fluroscopic images were viewed. Next sensory stimulation was obtained at each level at or below 1Hz up to 1 volt."

The above note describes the technique to treat the lateral branches of that innervate the SI joint. CPT Assistant has confirmed that 64640 can be reported for individual nerve destruction whereas they state a probe that targets multiple nerves would be 64999. 

The note has to support separate individual treatment at each S1, S2, S3 to support 64640 x 3. The note would have to state that separately at each S1, S2, S3 anatomical locations that non-pulsed radiofrequency ablation was performed. The temp and time appears to be non-pulsed.

For the two level facet medial branch denervation, the documentation does not support for example that L3, L4, L5 medial branches received radiofrequency ablation to support reporting 64633 64636. 

You can not proceed with any billing until the exact medial branches that innervate the exact facet joints are documented such as L3, L4, L5 were treated contributing to L4-L5, L5-S1 to support 64635 64636, without documentation of the medial branches treated to support 2 levels. You can not report 64635 64636. Currently it states the L5 dorsal ramus only, was also L4 medial branch treated to support 64635 in addition to 64640 x 3 for S1, S2, S3?

You will need an addendum or revised note before you can bill the described codes presented by the physician.


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## Jinx75 (Sep 11, 2013)

dwaldman said:


> You need to indicate to the physician that each individual nerves treated need to be indicated in the note: Have an addendum be made or revised note if not past thirty days.
> 
> "For lateral branch radiofrequency lesioning a 150mm, 20 gauge (with 15mm active tip) curved radiofrequency needle was guided using oblique fluoroscopic views to make boney contact between the appropriate sacral foramen and the sacroiliac joint. Lateral fluroscopic images were viewed. Next sensory stimulation was obtained at each level at or below 1Hz up to 1 volt."
> 
> ...



Thank you so much for this detailed explanation, I sincerely appreciate it and will get my Dr to do an addendum.

One more question, I spoke with the Dr about the procedure and she stated the patient is fused at L3-L4 and that is why she did not ablate the medial branch at L3, L4...she only did the L5 dorsal ramus...so would that be 64640 as well?


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## dwaldman (Sep 12, 2013)

medial branch radiofrequency 

The procedure note states above as if it was separate from the lateral branch portion. You can review with the physician if the L5 treatment was lateral branch that contributed to the innervation of the SI joint. Or if this is more innervation of L5-S1, if L5-S1 facet it could be 64635 with the 52 modifier since the L4 medial branch was not also blocked since the L5-S1 would receive dual innervation and the complete procedure was not performed.


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