# 64483?



## codedog (Dec 1, 2010)

doc office says this is. 64483,64484, 64484x2 , 77003 
so one else says 64450
any agree, disagree ? 

POSTOPERATIVE DIAGNOSIS:  Lumbar spondylosis.  
OPERATION:  
1.	Diagnostic nerve blocks of the right L5, L4, L3, and L2 medial branches of the dorsal primary ramus.  
2.	Fluoroscopic needle guidance.  
D.
ANESTHESIA:  2% lidocaine 5 cc and sodium bicarbonate 8.4% 5 cc; monitored anesthesia care.
BLOOD LOSS:  None.
FLUIDS GIVEN:  200 cc Lactated Ringer's solution.
URINE OUTPUT:  None.
INJECTATE MIXTURE:  Preservative-free bupivacaine 0.5% 7 mL and Depo-Medrol 80 mg 1 mL.  
PROCEDURE IN DETAIL:
Informed consent was obtained, explained the risks, benefits and alternatives of the procedure to the patient.  Operative site was marked in the holding area.  The patient was taken to the procedure room and placed in a prone position on the procedure table.  The back and buttocks were prepped with ChloraPrep solution, and a sterile drape was applied.  A time out was performed to verify the correct patient, procedure, and laterality.  
Using fluoroscopy, the spine was examined.  The levels in question were visualized from an ipsilateral oblique angle.  A skin wheal was raised over the right L5 pedicle, and subcutaneous tissue was anesthetized with a 2% lidocaine mixture.  A 3.5-inch 22-gauge spinal needle was advanced with intermittent fluoroscopic guidance towards the 2 o'clock position of the pedicle.  Contact with bone was made.  The needle was walked off in a cephalomedial orientation and advanced several millimeters to lie on the path of the L4 medial branch at this level.  After negative aspiration, 2 mL of the injectate mixture was instilled through the needle.  
 thanks for your time.


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## Walker22 (Dec 1, 2010)

Based on the op note and dx I would code this as a medial branch block:
64493-RT
64494-LT


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## dwaldman (Dec 1, 2010)

Is this the whole procedure note for L2, L3,L4 medial branches and L5 dorsal ramus?
All I see

"The needle was walked off in a cephalomedial orientation and advanced several millimeters to lie on the path of the L4 medial branch at this level. After negative aspiration, 2 mL of the injectate mixture was instilled through the needle."

Where is the description of injections of L2,L3,L5?

Why is the physician calling this a transforminal epidural?  Does he believe that is what he performed? Where is he referencing the CPT codes that he is selecting---from a CPT book or superbill? Why is the other person you are working saying this is other peripheral nerve branch block ? Are they currently responsible for coding pain management?

I would address this with them and if this the whole procedure note all you have is the L4 medial branch being blocked at L5.


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## codedog (Dec 2, 2010)

so just 64493,ok  i will query the doc, thanks


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## dwaldman (Dec 2, 2010)

The thing is the procedure title versus the narrative are conflicting if this is the complete note. I would print out august 2010 CPT Assistant Q and A for facets and I would print out the Sept 2004 Facet article from CPT Assistant. I would highlight important points in the article that you want to share with the physician. I would photocopy from the CPT manual the page that has 64483 and 64493 codes. I would start out the conversation by stating you said the procedure (show him a copy of the op report) should be billed as 64483 64484 64484 x 2 77003. I would explain that first that add on codes are not billed separately as quantity one and then reported on a second line with quantity two. If this was a 4 level transforminal block it would be 64483 64484 x 3 77003. I would then show him the pages from the CPT manual. I would read over the descriptors of the codes and state you were suggesting 64483 but isnt this a medial branch facet block. I would then show him the CPT assistant articles which explain the descriptor of 64490-64495 which says, or the nerves that innervate the joint---I would explain that even though the joint receives dual innervation and it requires two separate injections for MBB, the code is still reported per facet joint level not per injection(s). For example, if you look at the august 2010 CPT Assistant article, they state that L3,L4,L5 innervate L4-L5 and L5-S1. It needs to be straight forward which facet levels are being blocked. This is where the title can be used to make the narrative portion make more sense. For example, L3,L4,L5 Medial branch block corresponding to L4-L5, L5-S1.  I would stress that the narrative description of the procedure should describe each of these medial branches being blocked and then they can say ok I see where each of these nerves are being blocked and this for these levels mentioned in the title and these levels match the number of levels they are reporting. If you don't have CPT Assistant, you can order these two back issues and these help the physicain understand the proper reporting of the codes so the documentation can represent this understanding.


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## dav4code (Jan 26, 2011)

Very helpful conversation. FYI, effective 01/01/11 the fluoro 77003 is bundled with 64483. Check your CCI edits and the notation in the CPT manual for these revised codes. However it's not all bad news,a cursory look at some of the EOBs, it seems that Medicare increased the reimbursement from about $80 (in this region, for a single level injection) to $97.


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