# Medial branch block



## MDPAYNE (Apr 7, 2010)

I need some help coding this i'm new to the pain management coding . 

The patients op report reads as follows:

Lumbar medial branch block:
Pt was placed in the prone position on the fluroscopy table. Sterile prep and drape was applied. The proper level for the needle placement was obtained using radiographic confirmation. Lidocaine 1% was used to anesthetize the skin. A 25-gage spinal needle was advances into the estimated location of the medial branches.then 4% lidocaine totaling 0.3cc's at each location was injected under fluro. The injection was done at the l5-s1 bilaterally -3 injections per side.

Thanks for your help


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## dwaldman (Apr 7, 2010)

So would this be L4 medial branch nerve blocked at L5, L5 blocked at sacral ala, and also S1 branch blocked considering it is contributing to L5-S1 on each side which would be 64493-50. It could of been listed as L4-S1 medial branch block or Medial branch block for nerves innervating the L5-S1 facet joint.


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## hgolfos (Apr 7, 2010)

64493-50  these procedures are coded by level not by number of injections or vertebra.  So as dwaldman said above, L5-S1 is one level, done bilaterally.


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## rkmcoder (Apr 8, 2010)

(These are my opinions and should not be construed as being the final authority.  Other opinions may vary.)

The procedure description that you gave us does not seem to make sense.  If three medial branch nerves were injected on each side, then that would suggest that two spinal levels were blocked, which would be coded 64493-50, +64494-50 (fluoro is included).  But, the description only indicates one level was blocked, and without a clarification from your physician (corrected operative report or addendum), all that can be coded is 64493-50 (fluoro included).  This is of course assuming that this was a 2010 date-of-service (DOS).  If you are coding a pre-2010 DOS, then look at 64475-50, 77003.  Be sure to also pay attention to the preference of the carrier regarding bilateral modifiers.

Richard Mann, your pain management coder
rkmcoder@yahoo.com


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## magnolia1 (Apr 8, 2010)

rkmcoder said:


> (These are my opinions and should not be construed as being the final authority.  Other opinions may vary.)
> 
> The procedure description that you gave us does not seem to make sense.  If three medial branch nerves were injected on each side, then that would suggest that two spinal levels were blocked, which would be coded 64493-50, +64494-50 (fluoro is included).  But, the description only indicates one level was blocked, and without a clarification from your physician (corrected operative report or addendum), all that can be coded is 64493-50 (fluoro included).  This is of course assuming that this was a 2010 date-of-service (DOS).  If you are coding a pre-2010 DOS, then look at 64475-50, 77003.  Be sure to also pay attention to the preference of the carrier regarding bilateral modifiers.
> 
> ...



I have to disagree with your response......The description of 64493 in CPT is "Injection, diagnostic or therapeutic agent. paravertebral facet joint 
(or the "nerves" innervating that joint), with image guidance, lumbar or sacral,
"single level".
Based on that, regardless of how many nerves were injected within that facet joint, the case described above would be coded 64493-50


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## MDPAYNE (Apr 8, 2010)

Thanks to all of you for your help. Have a great day!!::


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## rkmcoder (Apr 8, 2010)

magnolia1 said:


> I have to disagree with your response......The description of 64493 in CPT is "Injection, diagnostic or therapeutic agent. paravertebral facet joint
> (or the "nerves" innervating that joint), with image guidance, lumbar or sacral,
> "single level".
> Based on that, regardless of how many nerves were injected within that facet joint, the case described above would be coded 64493-50



(These are my opinions and should not be construed as being the final authority.  Other opinions may vary.)

There are two methods used to inject a facet joint.  First, put the needle in the joint.  Or, second, target the two nerves that innervate the joint.  This is nicely explained in a CPT Asst article (Sept 2004) (please substitute 64475-64480 with the 2010 codes 64490-64495):

"It should be further emphasized that codes 64475, 64476, 64479, and 64480 refer to the injection of a facet joint either by injection into the joint with one needle puncture or by anesthetizing the two medial branch nerves that supply each joint (two needle punctures). For example, a left-sided L4-L5 intra-articular injection performed with a single needle puncture would be coded as 64475. Injection of the L3 and L4 medial branch nerves supplying the L4-L5 facet joint would also be coded as 64475, even though two separate injections are performed to effect the same result."

So, there cannot be three injections at a level for facet injections, hence the verbage of the operative report is incorrect.  Since the doctor reported three injections per side, I believe he/she actually injected two levels, but the operative note only specifies one level, so that is all that can be coded without a corrected note or an addendum to the note.

Richard Mann, your pain management coder
rkmcoder@yahoo.com


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## marvelh (Apr 9, 2010)

For a period of time, some providers considered the L5-S1 facet joint to have innervation from 3 nerve branches rather than the standard two...
L4 medial branch that is injected at the L5 vertebral body
L5 dorsal ramus that is injected at the sacral ala
AND a communicating branch from the S1 spinal nerve.

Newer anatomic research has found that there isn't a communicating branch as once thought and many pain mangement providers now only inject the L4 medial branch and the L5 dorsal ramus to block the L5-S1 facet joint.

With that said, the provider is still only blocking 1 facet joint level - L5-S1 and as such would be reported as 64493


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