# Sacral Rhizotomy.....Help....



## COMPauditor (Apr 16, 2015)

Because their are no facet joints in the sacral region, I am quite hesitant to use CPT codes 64633-64636.  I am also not sure about using 64640, since this is for other peripheral nerve or branch.  I have done some research and some say use 64640 and other's 64999.  Not a fan of unlisted codes, but my thinking is geared more towards 64999.  Below is the procedure and technique, any guidance is extremely appreciated!!


Procedure: Sacral Rhizotomy at L5, S1, S2 and S3 lateral branches on the right side under fluoroscopic guidance.

Technique: The sacral region was prepped and draped in the usual sterile fashion using Betadine as the prep solution, under fluoroscopic guidance the sacroiliac joints as noted above were identified and marked. A contra-lateral oblique view was obtained. A line was drawn on the skin parallel to the joint approximately 1/3 to 1/2 the distance between the joint and a line connecting the lateral aspects of the posterior S1-S3 foramen. Local infiltrative analgesia was achieved by injection of 10 cc's of 1% Lidocaine using a 1 1/2 inch 25 gauge needle at the marked location(s) as noted above with infiltration through subcutaneous tissues down to the sacrum along a parallel line to the SI joint. A curve 100mm radio-frequency needle with a 10mm active tip was advanced just lateral to the joint starting at the sacral ala. Sensory stimulation was performed at each level noted above at 50Hz.  A radio-frequency lesion was performed at 80 degrees Celsius for a 90 second burn at the primary dorsal ramus at L5, lateral branch division(s) at each sacral level noted above. The needle was then turned 180 degrees toward the sacral foramen and a second radiofrequency lesion was then carried out in a manner analogous to the above.


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## rlh27 (Apr 16, 2015)

June 2012 CPT Assistant issue: 

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

A: 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.


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## rlh27 (Apr 16, 2015)

I found one more thing that might help:

December 2009 CPT Assistant issue:

Q: 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.

A: 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 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 description 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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## KMCFADYEN (Apr 20, 2015)

I would use 64640


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