# RFA of the Third Occipital nerve



## NESmith

I have a provider that is doing a Radiofrequency Ablation right Cervical Facet Joint  medical branch nerves; C2, C3, C4, C5, C6, and 3rd occipital nerve. He billed 64626-RT x 1 and 64627-RT, 64627-RT, 64627-RT, 64627-RT, 64627-RT. The insurance company is denying the 64627 stating this is an invalid procedure code for the 3rd occipital nerve. Any suggestions as to the correct CPT code for a RFA of the 3rd occipital nerve? Thanks as always for your help.


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## dwaldman

http://en.wikipedia.org/wiki/Posterior_branches_of_cervical_nerves

"Third
The posterior division of the third cervical is intermediate in size between those of the second and fourth

Its medial branch runs between the Semispinalis capitis and cervicis, and, piercing the Splenius and Trapezius, ends in the skin. While under the Trapezius it gives off a branch called the third occipital nerve, which pierces the Trapezius and ends in the skin of the lower part of the back of the head. It lies medial to the greater occipital and communicates with it."
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I need to look further to find some information that would be useful to you. Some of the information from different sources I pulled up on the internet described it differently so I didn't know which one to copy and paste as the most reliable. You almost need a medical text book to support that this would represent what the descriptor in the code describes: "paravertebral facet joint nerve"  If I see one of the physicians tommorow I can pose these questions--Is the third occipital nerve a "paravertebral facet joint nerve"? Or Could the 3rd occipital nerve be considered "other peripheral branch" as described in RFA code 64640?


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## NESmith

Thank You so mcuh. I will wait for your reply.


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## dwaldman

I saw the physician who is familiar with this procedure and has recently performed one and coded it the way your physician did. He had been seeing patients at the outlying facilities all day so the conversation was brief because was late in the day.

I asked the physician, "Is the third occipital nerve a paravertebral facet joint nerve?

He said the third occipital nerve was a paravertebral nerve but he did not believe it would be correct to call it a paravertebral facet joint nerve.

I asked the physician, "Could you refer to it as peripheral nerve?"
He said do mean in like in the code 64640 (he is familiar with this code he does SI joint lateral branch RF) I said yes. He said you could possibly call it. 

He did seem to come to the conclusion that 64627 would not be the appropriate code due to the descriptor's wording and how he felt that it was not a facet joint nerve. Confirming  whether you can compliantly report 64640 would have to come from the AMA's CPT Network. If I am able to pay for a question on this topic, I will create a new thread with part of my response, so I can follow up with you.


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## NESmith

I was wondering if the you were able to find out any additional information on this, dwaldman?  Thanks for all your great help.


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## dwaldman

Inquiry Question:
I believe  the below procedure  should be coded as such: 64626 (C2), 64640 (TON), 64627 (C3), 64627 (C4) 77003

Is it appropriate to report 64640 for destruction of third occipital nerve by radiofrequency ablation? 

Radiofrequency neuolysis cervical medial branches(facets) RIGHT X 4 Levels C2,TON, C3, C4 Fluoroscopy for needle guidance

Above was part of my question Below is part of their response

"64626  Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level

64627 x2  Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

77003 x1 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction

"It would not be appropriate to report code 64640 Destruction by neurolytic agent, paravertebral facet joint nerve; other peripheral nerve or branch.  The third occipital nerve is the medial branch of C-3 and its location is similar anatomically with performing a paravertebral facet joint injection.  However, the difference is that the location of the third occipital nerve may 
vary, so the physician may need to burn over a wider area to ensure capturing the third occipital nerve in the procedure."


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## NESmith

Thanks so much for all your help, but I am still confused. So which would be the correct CPT code to use since we can not use the 64640. Is the CPt code 64627 correct? It did not really sound like it. You're the best for taking so much time with me.


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## larkatin

Please clarify.  Does this mean that billing for 4 levels is not correct?  We are doing these now and I have been coding 64626 x1 64627 x3 77003 (LT or RT, depending on side).  Is the TON part of one of the 64627 levels and not a completely separate level?  I might not be understanding the final thread completely.  This morning's been a little like that!  Thanks!


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## dwaldman

I submitted saying 4 level nerve destruction (RFA) stating one of the levels (nerves) was the third occipital nerve. I ask if you choose 64640 for the TON. They came back and said they might have to burn over a wider area, but when they provided the coding they did not separately code the TON and stating it was part of the C3 medial branch. Trying recall the best of how it was stated and my interpretation is they don't feel that TON should be 64640 and they don't feel you should bill a separate level using the facet or RF codes. When this is a non-neurolytic medial branch block it seemed like double counting and it makes sense this is their response even though the physician's might feel they are doing extra work and should be paid for it. I have not had a chance to go over with the physician in the group that usually performs this type of procedure that encompasses the TON.


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## NESmith

OMG that makes alot of sense. I like you think the provider does the extra work so he not necessarily over charges but want to be paid for the work that he does. What great information that you have provided. Thanks so very much. And, I am sure I will need your help in the near future.


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## Kelly_Josephine

*RFA Third Occiptal Nerve and/or C2-C3 ablation - understanding op reports*

I am trying to follow along here in an effort to better understand my own ASC coding for pain management injections... but I think there is too wide of a gap between my understanding of named procedures and actual procedural descriptions. I am a CPC-A and have only been coding less than one year. I have two op reports for the same patient/dx with what I believe to be the same procedures with only different laterality. I had thought to code the first report with ablation of TON, C3-C4, & C4-C5 with 64633-LT, 64640-LT & 64634-LT and the second report with like codes of 64633-RT, 64640-RT & 64634-RT. But now I am concerned that I am missing ablation of C2-C3 in addition to the TON. Since reading on the forums here, I understand that TON is likely inclusive in C2-C3 ablation, so maybe I should be coding 64633 and 64634x2? Truthfully, I can not tell from the details in these reports if this is just a TON ablation or TON with C2-C3 ablation.

I am hoping a knowledgeable pain coder will review these reports and explain what I should be looking for to decipher these procedures and/or direct me to some online resources that I can use to teach this to myself - I work independently from home as a contractor and I need to get this down. I find good information here and online, even though I have to translate the advice through the timing of the CPT changes rolled out - I think that some information is too old to trust despite my familiarity with the updates. 

Here are the two op reports that I am struggling with: 
POSTOPERATIVE DIAGNOSIS: Cervical spondylosis with cervical facet arthropathy. 
PROCEDURES PERFORMED:
1.	Radiofrequency ablation of the 3rd occipital nerve on the left side.
2.	Additional levels, C4 and C5 medial branch radiofrequency ablation on the left side.
3.	Fluoroscopy for precise needle placement.

INDICATIONS:  The patient is a pleasant 57-year-old female with complex medical history who has undergone a series of 2 successful diagnostic nerve blocks of the 3rd occipital nerve as well as C4-C5 medial branches bilaterally.   She   underwent right-sided radiofrequency ablation of the same nerves previously on August 31, 2015, with some relief in her pain.   She presents today to complete procedure and have the left side done.

1 - PROCEDURE IN DETAIL: An informed consent was obtained. The patient was taken to procedure room, was positively identified by the staff and the attending physician.  The patient was positioned prone on the procedure bed.  Vital signs   were monitored as above and remained stable throughout the procedure. Monitored anesthesia care was utilized for the procedure.  The skin was prepped and draped in a standard sterile fashion with chlorhexidine, followed by Betadine. A surgical pause time-out was performed and was agreed upon by the members of the team. A fluoroscopic view of the cervical spine was obtained and area of interest was identified. The skin was anesthetized using 1% lidocaine and-gauge 1.5-inch needle. 

After that, a 20-gauge 10cm RF cannula with 10mm active tip was advanced slightly above the C2-C3 facet joint on the inferior portion of the C2 lateral mass on the right side. The needle's position was verified in the lateral view in order to assure the tip of the needle was in the appropriate position in the inferior portion of lateral mass. Additional RF cannulae were placed in the C4 and C5 lateral masses in the mid portion of each articular pillar on the left side. Full contact with the osseous structures was established.  Each level was stimulated for sensory fibers at 50 hertz and the patient's pain was reproduced between 0.3 and 1 V. The motor fiber recruitment was ruled out by stimulation at 2 hertz in the range between 0.5 and 2.5 V, only localized twitching of the paraspinal muscles was elicited. The patient was specifically without any radicular complaints. Prior to lesioning, each nerve was then anesthetized with 0.5 m of 1% lidocaine. This was not carried out at third occipital nerve region as further cannulae were subsequently placed at the midpoint of C2-C3 facet joint as well as superior portion of the C3 lateral mass corresponding to the inferior portion of the C2-C3 facet joint to anesthetize other known locations of the 3rd occipital nerve. Again, local was not administered prior to lesioning at the 3rd occipital nerve area in an effort to maintain the ability to perform sensory motor stimulation. Before removing the radiofrequency cannulae, 1 lesion was performed at each site at 70 degrees for 105 seconds. The radiofrequency cannulae restyletted and removed at the end of the procedure. All needles were withdrawn. Patient tolerated the procedure well. The patient was transferred in stable condition to the recovery room.

2 - PROCEDURE IN DETAIL: An informed consent was obtained. The patient was taken to the procedure room and was positively identified by the staff and the attending physician. The patient was positioned prone on the procedure bed. The vital signs were monitored as above and remained stable throughout the procedure.  Monitored anesthesia care was utilized for the procedure. The skin was prepped and draped in standard sterile fashion with chlorhexidine.  A surgical pause time-out was performed and was agreed upon by the members of the team. A fluoroscopic view of the cervical   spine was obtained, and the area of interest was identified. The skin was anesthetized using 1% lidocaine and 25-gauge 1-1/2-inch needle.

After that, a 20-gauge 10-cm RF cannula with 10-mm active tip was advanced slightly above the C2-C3 facet joint on the inferior portion of the C2 lateral mass on the right side.  The needle's position was verified in the lateral view in order to assure that the tip of the needle was in the appropriate position in the inferior portion of the lateral mass. Additional RF cannulae were placed at the C4 and C5 lateral masses in the mid-portion of each articular pillar on the right side.   Full   contact with osseous structures was established. Each level was stimulated for sensory fibers at 50 Hz, and the patient’s pain was reproduced at approximately 0.8 V. The motor fiber recruitment was ruled out by stimulation at 2 Hz in the range between 0.5 and 2.5 V. Only localized twitching of the paraspinal muscles was elicited. The patient specifically denied any radicular complaints.  Prior to lesioning, each nerve was then anesthetized with 0.5 ml of 1% lidocaine.  This was not carried out at the third occipital nerve region, as further cannulae were then placed at the midpoint of the C2-C3 facet joint as well as the superior portion of the C3 lateral mass corresponding to the inferior portion of the C2-C3 facet joint. Again, local was not administered prior to lesioning at the third occipital nerve area in an effort to maintain the ability to perform motor stimulation.  Before removing the radiofrequency cannulae, 1 lesion was performed at each area at 70 degrees for 105 seconds. The radiofrequency cannulae were restyletted and removed at the end of the procedure. All needles were withdrawn. Patient tolerated the procedure well. The patient was transferred in stable condition to recovery room. Due to extensive needle manipulation and concern for hematoma format ion, the decision was made to defer the left portion of this procedure to another date.

Thanks in advance!


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## marvelh

*Ton*

The third occipital nerve (TON) provides the primary innervation to the C2-C3 facet joint.  If thermal RF ablation is performed at the C2-C3 joint denervating the TON, it would be "counted" as one facet joint level.  The documentation you included did not include procedure description of the C4 & C5 medial branch RF ablation, only the TON procedure twice.  IF the documentation does include description of the C4 & C5 medial branch RF ablation, then this would be a second facet joint level.

IF all three nerves (TON, C4 and C5 medial branches) were thermally radiofrequency ablated, then the coding would be 64633-LT x 1 and 64634-LT x 1

IF this procedure was performed in 2016, there is an issue in that the temperature documented was only 70 degrees Celsius and 2016 CPT includes a new parenthetical note specifically for 64633-64636 codes: "Do not report 64633, 64634, 64635, 64636 for non-thermal facet joint denervation including chemical, low-grade thermal energy (< 80 degrees Celsius), or any form of pulsed radiofrequency.  To appropriately report any of these modalities, use 64999"   SO if performed in 2016, this would be 64999 x 1.


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