# Bilateral sacroiliac joint radiofrequency - I need help with this op note



## ortho1991 (Mar 20, 2013)

Hi All,

I need help with this op note.

The patient was taken to the operating room and placed in the prone position. She was
prepped and draped in sterile fashion. Using fluoroscopic guidance, in the AP view, I visualized
the left sacroiliac joint. The target sites for ablation were the bilateral L5 dorsal ramus and
lateral branches of the bilateral S1, S2, and S3. I started first with the left S3 lateral branch.
The target site was the inferolateral border of the foramen. Intermittent fluoroscopic guidance
was used to get to the target site. Prior to insertion of the needle, subcutaneous 1% lidocaine
was injected. At this site, sensory and motor testing were completed. There were no
paresthesias or pain into the patient's lower extremities. Prior to radiofrequency, 0.5 mL of
2% lidocaine was injected through the SMK-type needle. The needle gauge was an 18-gauge
and length was 3-1/2 inches. The site was lesioned at 80 degrees for 90 seconds. The needle
was withdrawn. I carried out the same procedure for the remaining sites as mentioned above.
The patient tolerated the procedure well.
The patient was taken to the recovery room and monitored. She was sent home with discharge
instructions.

I looked at 64640 but really not sure.

I am new to pain mang. and any help or suggestions with this code will be appreicated
Thank you


----------



## magnolia1 (Mar 20, 2013)

Look at codes 64635 and 64636


----------



## dwaldman (Mar 21, 2013)

Per the AMA CPT Assistant  64640 would the correct code selection lateral branch nerve destruction and they indicate if separate individual  nerve destructions are performed, 64640 could be reported per nerve destruction. I would double check with the physician but  when he is mentioning the L5 dorsal ramus  does mean the lateral L5 branch corresponding to the SI joint under 64640. Or medial branch as seen with 64635

June 2012 page 15

Frequently Asked Questions: Surgery: Nervous System

Question: May code 64640 be reported for each individual peripheral neurolytic nerve destruction procedure performed at the L5, S1, S2, and S3 nerves? 

Answer: Yes. When performing individually separate nerve destruction, each peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, for peripheral nerve root neurolytic blocks (destruction) of L5, S1, S2, and S3, code 64640 should be reported four times. The coder should append modifier 59, Distinct Procedural Service, to the second and subsequent listings of code 64640 to separately identify these procedures.


December 2009 CPT Assistant

"Question: Should code 64640 x4 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. 

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 contri-buting 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)."


----------



## dwaldman (Mar 21, 2013)

"Radiofrequency neurotomy has targeted the L5 dorsal ramus and its branches to the SI joint, as well as the lateral branches of the S1–S3 dorsal rami"

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684948/

As seen in above link they describe the L5 dorsal ramus which is also seen with facet joint blocks and denervation blocked at the sacral ala, But in this situation they describe "its branches to the SI joint" which for treatment of sacroiliac joint dysfunction I would lean more towards 64640 for this level if there was no indication there was treatment of facet joint pain originating from L5-S1.


----------

