# need help or guidance or something



## TiffianyEdwards (Mar 18, 2015)

Does anyone have any resources for learning pain management and RA procedures. I am coding multple spec's and pain management I am so lost on what I am reading. 

Planned Procedure: Radiofrequency ablation of the Right C4-5 C5-6, and C6-7  facet joints, C4,C5,C6,C7 medial branch nerves
Levels: Right C4, C5, C6 and C7  For the Right C4-5, C5-6 and C6-7 facet joints
The C4 and C5 medial branch nerves innervate the C4-5 facet joint  
The C5 and C6 medial branch nerves innervate the C5-6 facet joint
The C6 and C7 medial branch nerves innervate the C6-7 facet joint


Pre/Post-Procedure Diagnosis: 
1.  Cervical spondylosis   IR Paravertebral Facet Joint Neurolysis 1 Facet Cervical Thoracic Right  
  IR Paravertebral Facet Joint Neurolysis 1 Facet Cervical Thoracic Right  

Informed Consent:  The patient's condition and proposed procedures, risks, benefits and alternatives were discussed with the patient in detail.  All questions were answered in detail and the patient chose to proceed.   Informed consent was obtained.       
Time Out: A time out verifying correct patient, medical record number, allergies and surgical site was performed immediately prior to beginning the procedure.
IV: Peripheral IV access was obtained.  A 22g IV was placed in the patient's hand
.
Sedation: Versed 1 mg Fentanyl 50mcg
HPI: Ms. Wilkinson is a 53 y.o. female who presents with neck, upper back and shoulder pain.  Previous treatment has included Medial branch blocks Helped. The patient reports >50% benefit from these blocks.
Procedure Description: The patient was placed in the prone position and made comfortable on pillows.  Pulse oximetry and noninvasive blood pressure cuff were monitored throughout the case.   
The skin of the neck was prepped with ChloraPrep and draped in sterile fashion. C-arm fluoroscopy was used to obtain a AP view in order to facilitate a AP approach to the target points at the midpoint of the 2 vertices of the quadrangle of the articular pillars on lateral view and the midway between the superior and inferior articular surfaces of the vertebrae at the "waist" of the pillar in AP view. The skin puncture sites were anesthetized with 2 mL 1 % Lidocaine.  A 50 mm radiofrequency canula was used. The cannula was advanced advancement, at each level, using AP and lateral fluoroscopic guidance.  Final needled positioning was performed in the lateral fluoroscopic view and the cannulas were advanced to the target point. In the case of the third occipital nerve, two radiofrequency cannulas were placed slightly superior and inferior to the C2-3 facet joint in lateral view. Confirmed needle tip on bone.  Once all needles were considered to be in a satisfactory fluoroscopic position, sensory and motor stimulation was performed.  Sensory stimulation was performed at 50 hertz, and was considered positive if pain was reproduced in a concordant fashion at a voltage at less than 1 millivolts. With motor stimulation, the goal was to see the absence of radicular upper extremity motor twitching or pain at the voltage greater than three times the magnitude of the sensory threshold. Specific parameters are available for review in the chart. This was performed for all levels. After satisfactory sensory and motor stimulation was complete, 0.5mL of 2% Lidocaine was placed through each needle.  Lesioning was then performed at 80 degrees Celsius for 90 seconds at each level.  The patient tolerated the procedure well.  All needles were removed and Band-Aids were placed.
No immediate complications were observed.
C4: Sensory 1.6 Motor 3
C5: Sensory 1.2 Motor 2.0
C6: Sensory .5 Motor 1.5
C7; Sensory .7 Motor 1.5
Outcome: Patient's pain score was 7/10 before the procedure and 5/10 after the procedure. After meeting discharge criteria, the patient was discharged home with her escort/driver.  
Impression/Follow-Up: XXXXXXX  will follow up in 4 week to decide on the longer-term effects of today's procedure and consider RFA of the left at that time.  She was instructed to call immediately if any of the following develops: new upper extremity neurologic symptoms, fever, worsening pain, headache, or any other symptoms


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## dwaldman (Mar 19, 2015)

AMA CPT Assistant Online would be a coding subscription that would want to be maintained for reviewing coding guidance for pain management coding.
Below for example, they recently have reviewed Radiofrequency Ablation procedures. In your scenario that you provided they are describing 4 medial branches that innervate 3 facet joints. As seen below, CPT 64633 64634 64634 would be reported as you are instructed to report per facet joint not per medial branch ablated. 


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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