# Confused on nerve injections in sacral region



## dodo3000 (Dec 4, 2012)

I'm a little lost in reading some of the posts when it comes to the sacral nerves and whether they are peripheral blocks vs. facet joint injection/MBB. The providers I work with do not typically state "lateral" or "medial" in their documentation for sacral nerves; it is often just "dorsal rami". Would it be correct coding in thinking if:

1. Right L3, L4 medial branch and L5 and S1 dorsal rami blocks with local anesthetic under fluoroscopic guidance = 64493 & 64494?

2. If the provider was documenting anything below S1, I need to get more information on what nerve is being treated, i.e., lateral, medial, etc.?

Thanks,

Angela Anderson, CPC


----------



## Michele Hannon (Dec 4, 2012)

The sacrum is one bone.....triangular in shape. It does not contain joints (facet joints) like other bones of the spinal column. It does provide protective cover for nerves that provide motor and sensory innervation to the posterior thigh and most of the lower leg and foot. The peripheral nerve that we most commonly see blocked that comes from this area is the sciatic nerve. The sciatic nerve splits into the popliteal and tibial nerves and we commonly block these for foot/ankle surgery.

Moving on.....the lumbar vertebrae do, indeed, have joints. Each vertebrae have four joints......two on the right side of the vertebrae and two on the left side of the vertebrae. On each side, one joint articulates with the vertebrae above and one with the vertebrae below......these are commonly referred to the intra-articular joints.
Each facet joint receives innervation from two separate spinal nerves: the branch from the spinal nerve exiting above the facet joint and the branch from the spinal nerve exiting AT the vertebral joint level......for example: L3-L4 facet joint and the medial branches that innervate it receive partial innervation from the medial branch of the L2 spinal nerve that exits between the L2-L3 vertebrae and partial innervation from the medial branch of L3 spinal nerve that exits between the L3-L4 vertebrae.
There is an exception to this rule.......some providers (docs) believe that a branch from the S1 spinal nerve also provides innervation to the L5-S1 facet joint.......these providers consider this facet joint to have THREE medial branch innervations (L4,L5 and S1). Regardless of the number of needles inserted or the number of nerves blocked at one spinal level, one CPT coder per spinal level is reported.
The following link may help with anatomy. Please PM  me with additional questions.
http://antranik.org/peripheral-nervous-system-spinal-nerves-and-plexuses/


----------



## dodo3000 (Dec 4, 2012)

I understand the thought process for the L4, L5, and S1 scenario that you pointed out, along with the basic anatomy of the sacrum. 

What I'm not understanding is the CPT Assistant Q&A from June 2012 where they are saying that S1-S4 nerve injections are considered peripheral nerves, coded with 64640 for destruction/ablation with apparently an older article discussing injections coded with 64450, and how you would determine that from a report. A lot of examples I've read on the forum here and elsewhere refer to the lateral branches of the sacral nerves - would every type of sacral nerve branch be considered peripheral or are there exceptions?

I honestly have never seen this differentiation before and didn't know it existed, so I want to make sure I'm coding this right going forward.


----------



## Michele Hannon (Dec 5, 2012)

ALL nerves eventually become peripheral nerves.
The link offers a great representation of this.
Note the peripheral nerves of the sacral plexus:sciatic, tibial, pudendal, posterior femoralcutaneous......as stated above, these peripheral nerves provide sensory and motor innervation to the posterior thigh, perineum, ankle and foot.
These peripheral nerves are commonly blocked for ankle and foot surgery. It would be best if your provider reported the nerve/s that were blocked/ablated/destructed.


----------



## dwaldman (Dec 5, 2012)

This was the initial CPT Assistant that describes the use of 64640 for the lateral branches of S1-S4 contributing innervation to the sacroilliac joint. I think Michele provided you some great information but thought I would copy and paste this one in the situation you hadn't seen it before.

December 2009 page 11

Bonus Feature:Surgery: Nervous System

Question: Should code 64640 x 4 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).


----------

