# 64633-64636 billable units



## tschrader (Feb 20, 2015)

We are having a little bit of a debate on these codes and how many units can be billed on the secondary code. We are wanting to bill these out correctly. Information we have recd can be confusing. So I am throwing this out there for other coders opinions. On the sample documentation below. We coded 64633x1 and 64634x1 but the debate is it should be 64633x1 and 64634x2. So if t5-T6, T6-T7, and T7-T8 is injected I am seeing this as 64633x1 64634x2. This is how I see it but I can also see it coded the other way too. Can be so confusing! Please help us to go in the right direction.



Pre/Post Procedure Diagnosis: 
1. Thoracic Spondylosis
2. Thoracic Intervertebral Disc Disease
3. Thoracic Facet Mediated Pain
4. Chronic Mid Back Pain

Procedure: 
1. left T5, T6, T7 and T8 Radio-Frequency Ablation (RFA)
2. Fluoroscopic Needle Localization

Procedure Summary:

The risks and benefits of the procedure were discussed with the patient who agreed to proceed via written consent. The patient was escorted to the fluoroscopy suite and placed in the prone position on the procedure room table. The thoracic region was cleaned with chlorhexidine x 3 then draped in the usual sterile fashion. A time out was performed to confirm this was the correct patient, procedure, and location. All pressure points were checked, padded, and verbal communication was maintained with the patient throughout the procedure. 

AP fluoroscopy was used to identify the T5, T6, T7 and T8 vertebral bodies. The image was optimized to visualize the junctions of the _left_ superior articular processes with the transverse processes at the target levels.
The skin and subcutaneous tissue inferior to those junctions was anesthetized with 1% lidocaine. A 20-gauge RF Stryker needle was then advanced percutaneously through the anesthetized skin tracts under fluoroscopic guidance until the non-insulated portion of the needles lie at the junctions of the above mentioned superior articular processes and transverse processes. All needle tips were confirmed to be posterior to the neural foramen in the lateral fluoroscopic view. Motor stimulation was performed up to 1.5V at each level producing stimulation of the multifidus muscles of the back and no stimulation of the lower extremity at any level. Each level was then anesthetized with 1% lidocaine prior to treatment with pulsed radiofrequency thermocoagulation for 120 seconds at 42 degrees Celsius. Each level was then treated with thermal radiofrequency thermocoagulation at 60 degrees Celsius for 90 seconds. Prior to the removal of each needle, a volume of 1 mL consisting of 10 mg of triamcinolone mixed with 1 mL 0.25% bupivacaine was injected at each site. The needles were flushed and removed and band-aids were applied over the needle puncture sites. 
The patient tolerated the procedure well and and there were no complications. After being monitored post-procedure, the patient was discharged to home in stable condition without any new neurologic deficit.


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## anarmst05 (Feb 21, 2015)

Procedure: left T5, T6, T7 and T8 Radio-Frequency Ablation (RFA)

You code it by level - you did 3 levels ... so the proper code will be 64633X1, 64634X2.

64633 - RF Cervical or Thoracic, single facet joint
64634 - RF Cervical or Thoracic, each additional facet joint ( key word here is EACH )


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## LisaAlonso23 (Feb 22, 2015)

I completely agree with the response above. That's the correct way to code this scenario.


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## dwaldman (Feb 23, 2015)

AMA CPT Assistant just addressed coding these procedures, which corresponds with the reporting that was suggested in the other posts you received.

AMA CPT Assistant February 2015 page 9

Coding Clarification: Reporting Paravertebral Facet Joint Nerve Destruction Codes (64633-64636)

To better describe the work involved in performing paravertebral facet joint nerve destruction, new codes (64633-64636) were established for the Current Procedural Terminology (CPT?) 2012 code set. Prior to 2012, injections of the facet nerves were differentiated based on the anatomic location and the number of levels (ie, single, second, and any additional level) at which these procedures were performed. 

Destruction by neurolytic agent of the facet nerves is now reported based on the number of facet joints that are treated using the codes from the 64633-64636 series. This coding structure more accurately describes the work involved in facet joint nerve destruction. When both facet joints at the same level are treated, one of the parent codes (64633 or 64635) may be used with modifier 50, Bilateral Procedure, appended. Because the bilateral modifier 50 accurately describes the work performed, it would not be appropriate to report two units of service in this circumstance. 



64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

64634 cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

64635 lumbar or sacral, single facet joint

64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Although two nerves innervate each facet joint, the number of nerves treated does not affect code selection. This is reflected in the term "nerve(s)" which is included in the code descriptors. Therefore, only one unit of service may be reported for each joint regardless of the number of nerves treated. To clarify, the typical patient has two nerves treated for each facet joint. These nerves are at two different vertebral levels; however, the code is reported once per joint treated no matter how many nerves are treated. 

In keeping with other procedures involving the vertebra, the code structure is based on spinal region. Codes 64633 and 64634 specify the cervical and thoracic regions, while codes 64635 and 64636 specify the lumbar and sacral regions. Codes 64634 and 64636 are add-on codes. These codes are reported for each additional facet joint at a different vertebral level in the same spinal region. Because each additional level is reported using codes 64634 and 64636, modifier 51, Multiple procedures, is not appended to these codes. If the additional level(s) is treated bilaterally, modifier 50 may be reported. It is important to note that the procedure must be adequately documented in the medical record...............


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