# SI Joint RFA procedure Code



## minte1 (Apr 19, 2013)

I need some clarification for coding a SI RFA, I have been given 3 different answers for coding; 64640, or 64640 with 64635,  or 64640 with 64999?  Please see note below:
Any help would be greatly appreciated, Thank You!  

Procedures 
RFA (Strip Lesioning) of SI Joint:  
       Consent Patient's history and physical exam were reviewed. The risks, benefits and alternatives to the procedure were discussed and all the questions were answered to the patients satisfaction. The patient agreed to proceed and written informed consent was obtained. .  
       IV Yes.  
       Anesthesia Monitored Anesthesia Care.  
       Location(s) Right .  
       Fluoroscopy Yes.  
       Prep Chloroprep.  
       Needle 17 G diamond tip probe.  
       Meds 6 ml 40 mg Depo-Medrol 0.25% Marcaine.  
       Procedure After obtaining informed consent; the patient was brought to the procedure room, placed in the prone position with a pillow placed beneath the abdomen to reduce the lumbar lordotic curvature. A dispersal grounding pad was applied to the posterior thigh and the lower lumbar region and buttocks was sterilely prepared and surgically draped. An antero-posterior (AP) projection with a vertical position of the C-arm, centered on the inferior border of the ipsilateral sacrum was obtained. The target point at the ipsilateral, lateral, inferior border of the sacrum, just lateral to the S4 foramen was identified and a local anesthetic skin wheal was raised 1 cm below this target point using a #25-gauge 3-1/2 inch, curved, Quinke tip, spinal needle and 1% buffered lidocaine. The needle was then advanced to contact the sacral target point making sure that the sacrum was contacted at an appropriate depth and that the needle had not entered either the S4 or any other sacral foramen, or ventured inferior to the sacral margin and into the pelvic cavity. Once the periosteum was contacted, the needle was then advanced in a cephalad and slightly lateral direction, staying lateral to the sacral foramen, in contact with the sacrum, and medial to the joint, and advanced into the ligamentous tissue between the sacrum and ilium. Once advanced along this line to a point where no further cephalad advancement could occur, the stylette was removed and a syringe containing 4 cc of 4% lidocaine and 1 cc non-particulate steroid was injected as the needle was withdrawn, to anesthetize the lesion track. Additional injections of this local anesthetic solution were made along the intended lesion track as necessary to optimize patient comfort. Attention was then redirected to the initial target point at the inferolateral border of the sacrum. The electrodes were then inserted through the previously created skin wheal until contacting the inferolateral border of the sacrum and verifying that the tip did not enter a sacral foramen or proceed inferior to the inferior border of the sacrum. The electrodes were 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 electrodes advanced to the ipsilateral sacral ala and independent, active contacts were positioned adjacent to the S1, S2, S3, and S4 lateral branch innervation pathways. A lateral view was then obtained, confirming that the electrodes remained in contact with the sacral periosteum, followed the curvature of the sacrum up to the sacral ala, and the active contacts were in an appropriate position to lesion the lateral branches of S1, S2, S3, and S4 Lesioning was then carried out at 85 degrees centigrade for 60 seconds at each level. The patient tolerated the procedure well without complication and each electrode was removed without difficulty and verified to be intact..  
       Disposition Patient tolerated the procedure well and there were no complications. Vital signs remained stable throughout the procedure. The patient was taken to the recovery area where written discharge instructions for the procedure were given. .


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## dwaldman (Apr 20, 2013)

", that the electrodes advanced to the ipsilateral sacral ala and independent, active contacts were positioned adjacent to the S1, S2, S3, and S4 lateral branch innervation pathways. A lateral view was then obtained, confirming that the electrodes remained in contact with the sacral periosteum, followed the curvature of the sacrum up to the sacral ala, and the active contacts were in an appropriate position to lesion the lateral branches of S1, S2, S3, and S4 Lesioning was then carried out at 85 degrees centigrade for 60 seconds at each level."

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Based on the guidance from the AMA CPT Assistant, I would believe this appears to be not individual nerve destruction, but lesioning carried out simultaneously at the desired locations with multiple contacts on a single device is my interpretation. And this would be reported with 64999. Please see below
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AMA CPT Assistant 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).


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## minte1 (Apr 22, 2013)

Thank you very much for your information and help!


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