# SIJ Radiofrequency Ablation



## lcole7465 (Apr 27, 2018)

OK.. I'm really confused on this one and the information I'm finding is not helping.. hopefully I can find some clarification here. I have a doctor that performed a Lumbar RFA @ L5-S1, he also performed an SI Joint RFA via denervation of L4,L5, lateral branches of S1, S2, S3. The op report reads:

*Procedure: Lumbar RFA:* 
Fluoroscopic evaluation was utilized to target the appropriate treatment areas. The skin was prepped with antiseptic solution and draped sterilely. Then 1% lidocaine was used to anesthetize the skin and subcutaneous tissue. Under Fluoro guidance a 20 gauge x 10 cm x 10 mm active tip was advanced to the medial branch nerve at the indicated levels below to denervate the following facet joints, Left L5-S1. The needles were placed sequentially. Position confirmed radio-graphically with the fluoroscope. Active tip corresponding at the base of the dorsal ramus of L5. Sensory stimulation was used to localize the nerve. Motor stimulation checked at 2hz and confirmed negative for radicular stimulation at 3 times the sensory threshold. After confirmation of of the needle placement the patient received 7cc of 0.5% Marcaine mixed with 10mg dexamethasone to provide anesthesia. Radio-frequency was delivered to the lumbar region. 90 degrees limit 90 seconds in length with no ill effect.

*Procedure: Left SI Joint Radio-frequency Ablation via denervation of L4,L5, lateral branches of S1,S2, S3:*
Utilizing a 22 gauge 5 inch spinal needle left SI Joint was injected with an anesthetic track of Marcaine was created along the line from the inferior boarder of the SI joint to the ala of the sacrum. Using the Simplicity RFA probe, and from a caudal cranial direction the probe was placed against the sacrum between the neuroforamen and the SI Joint. The RFA probe was advanced under fluoroscopy guidance, using AP and lateral views to confirm appropriate probe placement. Then using the neurotherm RFA generator and SI joint protocol, two bipolar and three uni-polar lesions were created with an 85 degree temperature limit with a 90 seconds treatment cycle for each lesion levels and nerves indicate. A 20 gauge x 10cm x 5mm active tip was advance to the dorsal ramus of L4 and L5 at this location.

Any help on this one would be appreciated..


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## dwaldman (Apr 27, 2018)

The simplicity probe is unlisted 64999, so the SI joint procedure that was performed is going to be unlisted.

AMA CPT Assistant December 2009
Surgery: Nervous System
Question: Should code 64640 x4 be reported per lesion because it is a single percutaneous entry point or should the unlisted code 64999 be reported? What is the appropriate code to use
for radiofrequency (eg, Simplicity III™ Radiofrequency Probe) for sacroiliac (SI) joint nerve destruction from a single percutaneous entry site in the following procedure?
The Simplicity III electrode was then advanced, maintaining continuous contact with the sacrum, on a cephalad and slightly lateral line, staying lateral to
the sacral foramen, medial to the sacroiliac joint, and ventral to the ilium, until contact with the sacral ala prevented further advancement. Appropriate positioning
was confirmed by changing the caudal/cephalad tilt of the C-arm to parallel the superior endplate of S1; and verifying once again that the entire length of the
Simplicity III electrode was advanced to the ipsilateral sacral ala and the three independent, active contacts were positioned adjacent to the S1, S2, S3, and S4
lateral branch innervation pathways…. “Lesioning” was
then carried out using the Simplicity III preprogrammed
protocol at 85 degrees centigrade for five minutes.
Karen Glancy, CCS-P

Answer: Since the documentation indicates insertion of a single electrode (having three contacts) at the sacroiliac
(SI) joint “to lesion the lateral branches of S1, S2, S3, and S4,” code 64999, Unlisted procedure, nervous system, is
reported once. This “SI joint rhizotomy” would be reported once using the unlisted nervous system code 64999. 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 contributing 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).  Therefore, the unlisted nervous system code 64999 would
be reported once for SI joint or sacral rhizotomy (nerve destruction). To differentiate between the work when performing sacral
nerve destruction of S1, S2, S3, and S4, 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. In this instance, code 64640 is reported four times.  It is suggested that Modifier 59, Distinct Procedural Service,
be appended as well. It is very important that the service performed matches accurately with the descripton in the CPT code. Therefore,
for this very reason, it is important to remember that a code that is “close” to the procedure performed is not
selected in lieu of an unlisted code. There are some who maintain that they are not allowed to use unlisted codes
or that the use of the unlisted codes is undesirable. While the use of an unlisted procedure code does require a special
report or documentation to describe the service, correct coding demands that you use a code that is appropriate for
the service being provided (ie, a code that most accurately
represents the services rendered and performed).


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