# Coding help on several RF procedures



## mgrimaldi (Sep 23, 2014)

I have a new pain management physician that wants to perform the following injections.  These are all new types of procedures to our office so they are uncharted territory for me as far as coding goes. I've tried to do my own research and found codes that may be accurate for some of them. Looking for someone to agree/disagree with my selections and/or help me with codes on the others marked ??.

Thanks in Advance

Trigeminal Nerve RF Lesioning (Divisions B1, B2, B3) - 64600 & 64605 or 64610
Sphenopalatine Ganglion Nerve RF Lesioning - ?? 64999
Cervical Dorsal Root Ganglion Nerve RF Lesioning - Is this your typical cervical facet code 64633, 64634
Lumbar Dorsal Root Ganglion Nerve RF Lesioning - Is this your typical lumbar facet code 64634, 64636
RACZ Catheter LESI Cryoneurolysis - ??
Supra Orbital Nerve RF Lesioning - Would this also be 64600 & 64605 or 64610?
Occipital Nerve RF Lesioning - Would this be 64640 for other peripheral nerve or branch?


----------



## dwaldman (Sep 23, 2014)

Cervical Dorsal Root Ganglion Nerve RF Lesioning - Is this your typical cervical facet code 64633, 64634
Lumbar Dorsal Root Ganglion Nerve RF Lesioning - Is this your typical lumbar facet code 64634, 64636

For the above, DRG RF would be unlisted 64999

RACZ Catheter LESI Cryoneurolysis - ??

For the above, would need to provider more information on what this involves, there is a standard lysis of epidural adhesion using a Racz catheter under 62264 or 66263 but don't see cyroneurolysis with these codes. There is also 62280 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid, but would need to know more about the procedure I am not familiar with it to give a code.


Supra Orbital Nerve RF Lesioning - Would this also be 64600 & 64605 or 64610?

 64600 appears to cover Supraorbital nerve RF

? 64600, Supraorbital, infraorbital mental, or inferior alveolar;

? 64605, Second and third division at the foramen ovale; and

? 64610, Second and third division at the foramen ovale with radiologic monitoring.


Occipital Nerve RF Lesioning - Would this be 64640 for other peripheral nerve or branch?

I agree that 64640 could be used. But a lot of the information I have seen on the internet regarding occipital RF is that it is performed as pulsed RF which would be unlisted 64999


----------



## dwaldman (Sep 23, 2014)

Sphenopalatine Ganglion Nerve RF Lesioning - ?? 64999

Yes, this unlisted procedure code 64999


Trigeminal Nerve RF Lesioning (Divisions B1, B2, B3) - 64600 & 64605 or 64610

64600, Supraorbital, infraorbital mental, or inferior alveolar;

? 64605, Second and third division at the foramen ovale; and

? 64610, Second and third division at the foramen ovale with radiologic monitoring


Below is from AMA CPT Assistant Dec 2008, I believe your above example refers to V1, V2, V3. As seen below in CPT Assistant they state 64400 is reported per single injection/single nerve.

From the RF standpoint it appears CPT 64600 represents the first division and then for example 64640 with image guidance is  reported for the second and third division


December 2008 page 9

Surgery: Nervous System, 64400 (Q&A) 

Question: If a provider injected two separate unilateral branches or divisions of the trigeminal nerve (eg, injected the right supraorbital branch [V1] and also injected the right infraorbital branch [V2]), would these injections be reported as two units of code 64400 or just one unit, as the code description states "any division or branch"? 

Marvel J. Hammer, RN., Denver, CO

Answer: Code 64400 should be reported once for the injection into the right supraorbital nerve. Code 64400 with modifier 59, Distinct procedural service, appended should be reported for the right infraorbital branch injection. The descriptor of code 64400 represents a single injection into a single nerve in the anatomy and sensory distribution of the peripheral trigeminal nerve. Injection of each specific nerves has effects on different anatomy sensation in different areas. 

An understanding of the neural distribution is key, since the right supraorbital nerve is above the orbit of the eye (about at the level of the eyebrow on the forehead), whereas the infraorbital nerve is below the orbit (lateral to the nose, middle of the face, and midline with the pupil of the eye). 

To illustrate, the trigeminal nerve is the main cutaneous sensory nerve of the face and head, with three main branches (V1, ophthalmic; V2, maxillary; and V3, mandibular), each with its own nerve divisions. The right frontal nerve is a continuation of the ophthalmic nerve. The right supraorbital nerve leaves the orbit through the supraorbital foramen, providing filaments to the upper eyelid and the frontal muscles. The right infraorbital nerve is in the maxillary branch of the trigeminal nerve. The maxillary nerve becomes the infraorbital nerve, which emerges onto the face through the intraorbital foramen, thus providing cutaneous innervation to the middle of the face, lower eyelid, side of the nose, and upper lip.


----------



## dwaldman (Sep 23, 2014)

for example 64640------I meant 64610 with image guidance.

62264 or 66263---I meant 62263


----------



## dwaldman (Sep 23, 2014)

I noticed 64605 and 64610 has a Medicare MUE of 1 which makes the descriptor of second and third division branches appear to include both branches in one code.

64610 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring 


Medically Unlikely Edits
Professional 1 units of service per day under most circumstances 


64605 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale 

Professional 1 units of service per day under most circumstances


----------

