# Need help coding RFA's



## BrettAAPC

Hi, I was hoping someone wouldn't mind reading through this doctor's procedure notes to help me figure out all the proper codes to bill out. I am very new to pain management and would be very appreciative if someone could give me some assistance.

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PROCEDURE TYPE: Radiofrequency ablation right L3, L4, L5 and S1 medial branches with the use of fluoroscopy.

INDICATION FOR PROCEDURE: Right-sided low back pain, spondylosis without myelopathy. The patient has 90% pain reduction from diagnostic injections 12/5/12 and he is still feeling better. He desires to undergo radiofrequency ablation as he is leaving for Florida for the winter. Risks and benefits were discussed including infection, bleeding, nerve injury, paralysis, headache, reaction to medication, failure to relieve pain and other potentially serious complications. He understands and wishes to proceed. We discussed he may experience 2-3 weeks of post procedure discomfort requiring continued use of pain medications.

DESCRIPTION OF PROCEDURE: The patient received an I.V. in the holding area. He ambulated to the procedure suite and placed himself prone on the procedure table. Timeout procedure verified correct patient and site. Standard ASA monitors were applied. He was sedated with Versed 2 mg and Fentanyl 50 mcg 7:57-8:33 with the assistance of _____ Skin was numbed with 9 mL of 1% Lidocaine. Using oblique fluoroscopy, 20 gauge Kimberly-Clark Radiofrequency Ablation probes, 10 cm in length with 10 mm active tip were advanced to right L4 and L5 levels for the L3 and L4 median branches. A needle was advanced to Barton's point at the transitional S1-2 level through the L5 dorsal ramus and to the sacral ala for the S1 lateral branch. Needle positions were confirmed under oblique, AP and lateral view of the spine. Aspiration was negative for blood or fluid at each level.

Impedance was 156 ohms at L3, 162 ohms at L4, 192 ohms at L5 and 190 ohms at S1. Sensory was positive at 1 volt at L3, 1 volt at L4, 0.45 volts at L5 and 1.15 volts at S1. Motor testing was negative for lower extremity stimulation at all four levels at 3 volts. I did have positive weak multifidus at L3 and positive multifidus at L4, L5 and S1. Each site was numbed with 1 mL of 2% Lidocaine. Primary lesions were conducted at 80 degrees for 90 seconds. The needles were then rotated and secondary lesions were conducted at 80 degrees for 90 seconds. The needle was slightly repositioned at S1. Motor was retested and this was negative for lower extremity simulation at 3 volts and positive for multifidus.

Needles were rotated at the other sites a third time. Tertiary lesions were conducted at 80 degrees for 90 seconds. The patient was awake and communicative during the lesionins.  There were no observed concerns. Total fluoroscopic time was 28 seconds. Each level was injected with one fourth of a mixture of 60 mg of Depo-Medrol and 3.5 mL of 0.5% Bupivacaine. There were no observed complications. The patient was escorted to the Recovery Suite via wheelchair, where he was observed and discharged in stable condition.

Post procedure examination: Alert and oriented x3. The patient is in no acute distress. Vital signs are stable. Motor strength is 5/5 in the bilateral lower extremities. DTRs are 2/4 in the knee and ankles. There are no sensory deficits of the lower extremities. Lumbar spine is minimally tender to palpation.

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Based on this, I would assume all that needs to be coded is 64635, 64636 x 3, 77003-26, and 99144.

Any help would be appreciated. Thanks!


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## dwaldman

721.3 

64635 RT L3 and L4 Medial branches innervating the L4-L5 facet joint
64636 RT L4 and L5 Medial branches, & S1  innervating the L5-S1 facet joint
99144 for 36 minutes (07 57-08 33) sedation

As seen below, CPT 77003 is required and no longer separately reportable with 64633-64636. They also aligned the reporting of these codes with facet injection codes 64490-64495 to be reported by facet joint level. Below is an example from AMA CPT Assistant of facet block performed at L3, L4, L5 and per the AMA this would represent L4-L5 and L5-S1 facet levels. The S1 would be included in L5-S1 level.





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AMA CPT Assistant Sept 2012

While the intent of the new code series has remained the same, the reporting of these procedures has changed: 
•The vertebral level is of less significance than the number of facet joints treated, so the unit of service is per facet joint to adequately reflect the work performed. 
•For consistency with other procedures involving vertebra in the CPT code set, these codes are structured based on spinal region: •Codes 64633 and 64634 specify the cervical or thoracic region. 
•Codes 64635 and 64636 specify the lumbar or sacral region. 
•Codes 64634 and 64636 are add-on codes for each additional facet joint in the same spinal region. 

•Image guidance and localization are required for the performance of paravertebral facet joint nerve destruction by neurolytic agent as described by codes 64633-64636. •Imaging guidance using fluoroscopy (77003) or CT (77012) is no longer separately reported with paravertebral facet joint nerve destruction by neurolytic agent as it is considered an inclusive component of codes 64633-64636. 

_________________________________________________________

AMA CPT Assistant August 2010 page 12

Surgery: Nervous System, 64490, 64491, 64492 (Q&A) 

Question: Lumbar medial branch blocks were performed on the right at L3, L4, and L5. Would codes 64490, 64491, and 64492 be reported because three different levels were injected? 

Answer: No. The L3, L4, and L5 medial branch nerves innervate the L4-L5 and L5-S1 facet joints. Therefore, code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level, is reported for the first joint injected or blocked (L4-L5). Code 64493 is reported for a single or initial level treated. Add-on code 64494, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure), is reported for the second joint or level injected or blocked (L5-S1). In this specific instance only, CPT codes 64493 and 64494 should be used, provided the injections were performed in the lumbar spine with fluoroscopic (or CT) guidance, as required to use codes 64490-64495. 

To further clarify, add-on code 64495, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure), is reported only once per day for injections at the third and any additional lumbar or sacral level(s) treated (which does not apply to this case). Codes 64494 and 64495 should only be used in conjunction with code 64493. 

CPT codes 64490-64492 are reported in the same way for cervical-thoracic facet injections or blocks. In addition, add-on codes 64492, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) and 64495 are reported once per day as a singular line item irrespective of the number of spinal levels treated


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## BrettAAPC

dwaldman said:


> 64635 RT L3 and L4 Medial branches innervating the L4-L5 facet joint
> 64636 RT L4 and L5 Medial branches, & S1  innervating the L5-S1 facet joint
> 99144 for 36 minutes (07 57-08 33) sedation



Thank you very much for your response. That info is very valuable and much of it I did not realize, so I appreciate it.

In regards to how you coded the procedure, can I just confirm that you would code this as 

64635 x 2, 64636 x 3? or is 64635 just x1 and is supposed to include L4-L5?

And then when coding 99144 do I apply any additional info like the time? Also what does (07 57-08 33) mean?


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## dwaldman

The radiofrequency procedures of the facet joints nerves may be described in the procedure note per medial branch but it is currently reported similar to facet block where you report per facet level not per medial branch that is blocked that innervates the facet joint. As seen below from 2004 AMA CPT Assistant  and additional resource, they give the example of two techniques: blocking the facet joint itself (intra-articular injection) or blocking the two medial branches that innervate the facet joint. They describe in the lumbar region that  the facet joint receiving innervation from at the same level and the level above so the following table would need to be understood:

T12, L1 Medial Branches innervate L1-2 Facet joint
L1, L2 Medial Branches innervate L2-L3 Facet joint
L2, L3 Medial Branches innervate L3-L4 Facet joint
L3,L4 Medial Branches innervate L4-L5 Facet Joint
L4, L5 Medial Branches innervate L5-S1 Facet Joint
+ If it is considered the S1 branch is contributing to the L5-S1 facet joint, this would be included in L5-S1 level.

The next step is determining if the medial branch is being referred to or if the anatomical location of the injection/lesioning is being referred to within the procedure note. In the procedure note you provided, it describes the medial branches at the top of the note so I assumed these were the medial branches that were described in the body of the report. L3,L4,L5,S1 were described as being treated with non-pulsed radiofrequency ablation. The time of the sedation was also provided in the report and it was 36 minutes, if the time was 38 minutes this would account for a second 15 minutes since the mid way point of the 15 minutes would of been met. I was listing the time to determine if this threshold was under or over the mid way point for additional reporting of 99145 or not. It was under so I only listed 99144. You would report 64635 with the RT modifier with quantity one for L4-L5 joint that was treated by lesioning the L3,L4 medial branches which supply innervation to that joint, You would report 64636 RT modifier with quantity one for the L5-S1 joint that was treated by the similar technique of lesioing the L4 medial branch, L5 dorsal ramus, and S1 branch.



_______________________________________________________________________ 

AMA CPT Assistant September 2004 page 1

The Facets of Paravertebral Facet Joint Procedures (64470-64476, 64622-64627)

Generally, each facet joint has dual innervation: one from the dorsal rami at the same level and one from the level above (eg, the L4-L5 lumbar facet joint is innervated by the medial branches of the dorsal rami from L3 and L4). Multiple injection levels are frequently performed when treating neck and upper back pain, as it is often difficult to isolate the exact joint level and two to three level injections may be performed at one sitting. Therefore, depending on the involved pathology, multiple-level facet joint and facet joint nerve blocks may be necessary for proper evaluation and management of chronic pain in a given patient. 

........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. 

___________________________________________________________
http://dardipainclinic.com/radiofrequency_rhizotomy.php


Anatomy And Physiology Of The Lumbar Facet Joint 

The lumbar facet, or apophyseal or zygapophyseal, joints are formed by the superior and inferior articular processes of successive vertebrae. On the dorsolateral surface of each superior articular facet is a prominence known as the mammilary body or process. There is also an accessory process which arises from the dorsal surface of the transverse process near its junction with the superior articular process. The size of the accessory process varies, and in the lower lumbar region it is frequently quite large, with considerable bony overgrowth of the base. 

The nerve supply of the lumbar zygapophyseal joints is derived from the dorsal primary ramus of the nerve root. The nerve which appears to be most closely associated with the joint is the medial branch of the dorsal primary ramus, and anatomical studies have delineated that each zygapophyseal joint receives innervation from two successive medial branches. Bogduk and Long9 have published an elegant anatomical study using cadavers which clearly establishes the anatomy of these nerves. They note that the lumbar dorsal rami of L1-L4 differ from that of L5. Figures 1 and 2 show a transverse and lateral view of the anatomy being discussed. At the L1-L4 levels, each dorsal ramus arises from the spinal nerve at the level of the intervertebral disc. It enters the back through a foramen in the intertransverse ligament. About 5mm from its origin, the dorsal ramus divides into a medial and lateral branch. The lateral branches continue into the longissimus and iliocostalis muscles of the erector spinae apparatus. The medial branch runs caudally and dorsally, lying against bone at the junction of the root of the transverse process with the root of the superior articular process. Here, the medial branch enters a fibro-osseous canal, created by the superior articular process, the transverse process, the accessory process, and the mammillo-accessory ligament. This ligament is often calcified, creating an entirely bony canal. 
Once emerging from this canal, the medial branch runs medially and caudally just caudal to the zygapophyseal joint, and becomes embedded in the fibrous tissue surrounding the joint. It continues across the lamina just deep to the multifidus muscle and sends a branch to the interspinalis muscle, and eventually enters the multifidus muscle. Terminal branches of the medial branch supply the ligaments and periosteum of the vertebral arches and spines.

The medial branch gives off two sets of branches to the zygapophyseal joints, named by Bogduk and Long the proximal and distal zygapophyseal joints. The proximal zygapophyseal nerve supplies the rostral aspect of the next lower joint. Thus, each zygapophyseal nerve from the medial branch related to it laterally, and the distal zygapophyseal nerve from the next rostral segment. This fact has important implications for facet nerve block and denervation procedures, as both branches need to be blocked or lesioned to completely denervate a single joint.

The course of the medial branch of the dorsal ramus is fixed anatomically at two points: at its origin near the superior aspect of the base of the transverse process, and distally where it emerges from the canal formed by the mammillo-accessory ligament. No reported variations of this anatomy have been found in the literature to date.9

At the L5 level, the transverse process is replaced by the sacral ala, and the L5 dorsal ramus arises from the spinal nerve just outside the L5-S1 intervertebral foramen, passing dorsally over the sacral ala in a groove formed by the junction of the ala with the root of the superior articular process of the sacrum. The medial branch arises as the nerve passes in this groove, and then wraps medially around the posterior aspect of the lumbosacral (L5-S1) zygapophyseal joint, terminating in the multifidus muscle. 

The biomechanical function of the facet joints is well-recognized. When standing, the lumbar facets carry approximately 16% of the spinal compressive load.10They are relatively unloaded while sitting. Yang and King have demonstrated that lumbar facets carry 3-25% of the spinal load in normal conditions, and up to 47% of the load when the facets are arthritic.11There is a close relationship between the intervertebral disc integrity, facet loads and spinal degeneration. With disc-space narrowing, as frequently occurs with spinal degeneration, there is increased load in the facet joints, especially in extention.11-13 The facet capsules are primarily loaded in flexion and in rotation, and thus the facet joints are the primary resistors against rotational or torsional forces.14 There is controversy as to whether increased loading of facets is a natural function designed to preserve the intervertebral disc, or whether this represents a pathological change capable of giving rise to pain.


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## BrettAAPC

So you're saying it's just 64635 x 1 and 64636 x 1 and 99144?

Sorry if that's not what you were saying, I am just a little confused. I thought for 64636 it meant each additional facet joint which would be L3-L4 (64635) and then L4-L5, L5-S1 (64636 x 2). Are you saying L4-S1 is just one additional facet joint?

And so a facet joint is a vertebral level such as L3-L4 and not a vertebral segment like strictly L4? If that's true then my doc has been coding wrong for a while.

I apologize if I am a little slow picking this up.


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## dwaldman

Pain management consultant Marvel Hammer RN BS CPC CCS-P ACS-PM CHCO, is the one who could really explain this. From webinars on facet coding that I have attended by her is how I have come to understand reporting these procedures. Such as the table of innervation I provide you is from one of her webinars.  I point this out because it can be very complex and there are a lot factors to consider as to not accidently under code or accidently code to many levels. 

This is the key point I think you are missing. First look at CPT 64493 descriptor for example: 

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 

Notice the following in the code descriptor:

"(or nerves innervating that joint)"

Then go back to September 2004 CPT Assistant

".....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."

See above how they are describing the L3 medial branch blocked at the L4 anatomical landmark, and L4 medial branch blocked at the L5 anatomical landmark, these medial branches L3,L4  provide innervation to L4-L5 facet joint. AMA CPT Assistant points out whether you block with one injection the L4-L5 joint or block with two injections the nerves innervating the joint it is still reporting only once since you report the codes per facet joint level. 

Look at your procedure note:

"10 cm in length with 10 mm active tip were advanced to right L4 and L5 levels for the L3 and L4 median branches"

Lesioning carried at the anatomical landmark of L4 to target the L3 medial branch and also the procedure is carried out at L5 anatomical landmark to treat the L4 medial branch. Since radiofrequency ablation procedures are reported per facet joint level, although two medial branches were treated you only report per the facet level that they innervate such as the L4-L5 joint. The L4,L5,S1 nerves are going to represent the L5-S1 level. Leaving you with only two facet joint levels thus 64635 64636. If the procedure note stated for example L2,L3,L4,L5 with L2,L3 innervating L3-L4, L3,L4 innervating L4-L5, and L4,L5 innervating L5-S1, you would have 4 medial branches/dorsal ramus blocked but only 3 facet joint levels. Although in the procedure note you have L3,L4,L5,S1, you are not getting the third level for S1 because it would fall under L5-S1 with L4,L5.


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## stlbill511

*RF's*

RF's are always denied for experimental and not deemed necessary, so can the doctor bill for an LESI instead?

Caroline


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## dwaldman

If  primarily ,the insurances the physician is billing denies RFA procedures, he could chose to do another treatment, since  an  ABN might be a high price for a radiofrequency considering the RVUs it has. But the way you worded the question sounded that you would bill another code in lieu of the RFA and but I would assume you could agree you could not do that.


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## stlbill511

No it is worded correctly.  Unfortunatley.  Do you have any advice on the first steps to reporting a physician for fraud?

Caroline


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## dwaldman

I think your first step is to have a meeting with those involved and agree on a plan to make sure that the carrier is refunded or provided a corrected claim. You can run a report to identify which services need to be refunded or rebilled. In this sense, once you have completed the refund and corrected claim process. Then you can focus on going forward to make sure that everyone identifies that you can only code straight from what was performed. And if the carriers doesn't cover it, it is the practice's responsibility to identify services that are non-covered and work with the patient to identify potentially alternative treatments that might be covered by their insurance. If you correct the past claims and make sure you are in compliance going forward then in the end I feel that it could be appropriately address in this manner.


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## stlbill511

I can't do that any more.  I was let go because I would not be a creative biller and would not think outside the box.   Other things like billing under physicians NPI for the NP when the doctor was home sick.


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## stlbill511

Do you know if I should get in touch with an attorney to protect myself.  

Caroline


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## dwaldman

Yes, I think it would beneficial to be able to review the situation with attorney who is familiar with healthcare and make sure you are following the necessary steps require by law.


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## denarh40

*Rfa*

Would you bill for the contrast itself for this procedure in an office setting?


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## cassyn86

denarh40 said:


> Would you bill for the contrast itself for this procedure in an office setting?



Contrast is bundled, cannot bill separately for it.


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