# Medial Branch Innervation



## kseeg23 (Mar 25, 2015)

I was just wondering if anybody could help me out with which medial branches innervate which nerves and/or anatomic vertebral location. Each anatomical location receives innervation from the medial branch above and the medial branch at the level is how I've understood it. So the vertebral segment L3 is innervated by the medial branches of L2 and L3 and vertebral segment L4 is innervated by the medial branches of L3 and L4. I get thrown off though when the documentation simply says L3 and I'm not sure if it's referring to L3 the vertebral segment or the L3 nerve. I think there was a table on here of the difference in the coding for when Dr documents L3, L4, L5 as Vertebral segments...and when he documents L3, L4, L5 and means the medial branches. Does that make sense? Answer as if I'm 5 and don't get it! Thanks!


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## dwaldman (Mar 26, 2015)

Typically you are looking at a 2 level block or 3 level block in the lumbar region.

The 2 level block would be the L3, L4, L5 (3 separate injections/ 2 facet joints treated).
With: 
L3, L4 innervating L4-L5  (L3 being blocked at L4, L4 being blocked at L5)
L4, L5 innervating L5-S1 (L5 being blocked at the sacral ala)

For the three level block, it would include the above but also consist of the L2, L3 medial branches innervating L3-4 facet joint.

This is a limited explanation and restating what you have in your question, but I think it comes down to trying query the physician on what was performed  (treatment of 2 or 3 facet joints). If the documentation is not clear, you have to state what needs to be changed so you can accurately capture the levels treated. If clear defined procedure heading stating the specific medial branches blocked. So you are not left just trying to decipher the narrative alone. Also the what was ordered for the patient to receive, what was consented for, and what the brief postoperative progess note states was performed can also be reviewed.


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## dwaldman (Mar 26, 2015)

https://www.aapc.com/memberarea/forums/showthread.php?t=23374

Above is a previous thread that I found describing the location of the vertebral segment where the medial branch is blocked. On my quick internet search I did not find a multiple level example but I think the above post represents this type of concept that has to be utilized for coding these procedures.

Below also describes the 2 level block scenario in the lumbar region consists of L3, L4, L5 medial branch block for the treatment of the L4-5, L5-S1 facet joints.

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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## kseeg23 (Mar 31, 2015)

Thanks! I know I can always count on you!


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## kseeg23 (Apr 1, 2015)

So how would you code this 2 procedures:

Procedure #1

THORACIC RADIOFREQUENCY ABLATION WITH FLUOROSCOPYTARGET SITES: T1, T2, T3, and T4 Bilateral (to denerve the joints at C7-T1, T1-2, T2-3, and T3-4). 
INDICATIONS FOR PROCEDURE: The patient has chronic back pain not relieved by conservative therapy. The thoacic facet joints were identified as a source of this patient's chronic back pain by diagnostic thoracic facet joint blocks which provided immediate, but temporary relief. Percutaneous radiofrequency denervation of the medial brach nerves supplying the painful facet joints is now planned to provide long lasting relief. 
PRE-PROCEDURE EVALUATION: Patient states she has been NPO for at least 4 hours, has a driver, denies current illness, infection or recent surgery, and has signed a procedure consent form. Patient states that she has not taken any anticoagulants in the last 14 days. Patient reports pre-procedure anxiety and is requesting sedation. PT/INR was not performed. 

VITALS: BP: 121/77 HR: 87 Temp: 98.6 O2 Sat: 96 
CURRENT PAIN SCORE: On a VAS scale from 0-10, the patient rates their pain currently at a 9. 
AVERAGE PAIN SCORE: Patient rates their pain on average at a 9. 

Anesthesia: An IV catheter was placed and made secure in the right AC. The following medications were given for sedation by intravenous injection: fentanyl 3ml versed 4ml. Sedation administration start time: 12:57 PM. Sedation end time: 01:15 PM. 
Prior to procedure an evaluation was performed. The procedure was explained to the patient. Initially a skeletal model was used to give a detailed procedure explanation. Potential complications including extremity numbness and weakness, loss of sensation, motor deficits, death, nerve damage, abnormal sensations, neurologic changes, temporary or permanent paralysis, generalized and/or central nervous system infection, bleeding, infection, headache and/or other serious or life threatening compliactions were explained to the patient. No guarantee of benefits were given. The patient agreed to have the procedure and signed the consent. 
The patient was taken to the procedure room and placed in the prone position. Standard non-invasive monitors were then applied. Confirmation of the procedure to be performed was obtained from the patient. The skin overlying the area to be treated was prepped with chlorhexadine and draped in a sterile fashion. The levels to be treated were visualized fluoroscopically in the AP and oblique views. A local anesthetic skin wheal was raised with 2% lidocaine using a 25 gauge needle at each of the levels. Under fluoroscopic guidance, a 20 gauge, 5mm active tip radiofrequency ablation needle was advanced to the junction of the transverse process and superior articular process. Proper needle placement was confirmed in the lateral, oblique, and AP views. There were no parasthesias during needle placement. Sensory, motor and multifidus thresholds were normal. Approximately 1ml of 2% lidocaine was injected at each level. One lesion was performed for 90 seconds and 90 degrees Celcius at each level. Approximately 10mg of Triamcinalone was injected at each level and the needles were withdrawn. The patient tolerated the procedure well and was brought to the recovery area in stable condition. The procedure was performed at the following levels T1, T2, T3, and T4 Bilateral. 
Radiation exposure time: 60 seconds 



Procedure #2

LUMBAR RADIOFREQUENCY ABLATION WITH FLUOROSCOPYTARGET SITES: L3, L4, L5 AND SACRAL ALA (to denerve the joints at L2-3, L3-4, L4-5, L5-SA) Left 
INDICATIONS FOR PROCEDURE: The patient has chronic lower back pain not relieved by conservative therapy. The lumbar facet joints were identified as a source of this patient's chronic lower back pain by diagnostic facet joint blocks which provided immediate, but temporary relief. Percutaneous radiofrequency denervation of the medial brach nerves supplying the painful facet joints is now planned to provide long lasting relief. 
PRE-PROCEDURE EVALUATION: Patient states he has been NPO for at least 4 hours, has a driver, denies current illness, infection or recent surgery, and has signed a procedure consent form. Patient states that he has not taken any anticoagulants in the last 14 days. Patient reports pre-procedure anxiety and is requesting sedation. PT/INR was not performed. 

VITALS: BP: 135/72 HR: 51 Temp: 97.4 O2 Sat: 96 
CURRENT PAIN SCORE: On a VAS scale from 0-10, the patient rates their pain currently at a 8. 
AVERAGE PAIN SCORE: Patient rates their pain on average at a 8. 

Anesthesia: An IV catheter was placed and made secure in the left AC. The following medications were given for sedation by intravenous injection: fentanyl 1ml versed 2ml. Sedation administration start time: 08:10 AM. Sedation end time: 08:40 AM. An independent trained observer monitored the patient's level of consciousness and physiological status throughout the procedure. 
Prior to procedure an evaluation was performed. The procedure was explained to the patient. Initially a skeletal model was used to give a detailed procedure explanation. Potential complications including lower extremity numbness and weakness, loss of sensation, motor deficits, death, nerve damage, abnormal sensations, neurologic changes, temporary or permanent paralysis, generalized and/or central nervous system infection, bleeding, infection, headache and/or other serious or life threatening complications were explained to the patient. No guarantee of benefits were given. The patient agreed to have the procedure and signed the consent. 
The patient was taken to the procedure room and placed in the prone position. Standard non-invasive monitors were then applied. Confirmation of the procedure to be performed was obtained from the patient. The skin overlying the area to be treated was prepped with chlorhexadine and draped in a sterile fashion. The levels to be injected were visualized fluoroscopically in the AP and oblique positions. A local anesthetic skin wheal was raised with 2% lidocaine using a 25 gauge needle at each of the levels. Under fluoroscopic guidance, a 20 gauge, 10mm active tip radiofrequency ablation needle was advanced to the junction of the transverse process and superior articular process. Proper needle placement was confirmed in the lateral, oblique, and AP views. There were no parasthesias during needle placement. Sensory, motor and multifidus thresholds were normal. Approximately 1ml of 2% lidocaine was injected at each level. Two lesions were performed for 90 seconds and 90 degrees Celcius at each level. Approximately 10mg of Triamcinalone was injected at each level and the needles were withdrawn. The patient tolerated the procedure well and was brought to the recovery area in stable condition. The procedure was performed at the following levels L3, L4, L5 AND SACRAL ALA Left 
Radiation exposure time: 26 seconds 

The patient was observed in the recovery area for pain relief and side effects. When stable the patient was discharged home with post procedure instructions. 


I feel like the joints listed in paranthesis don't match up with the listed "target sites" which according to the body of the note are referring to the medial branches but at the end of the note is says levels. Maybe I am missing something. I have to talk to the Dr, but I want to make sure I know what to clarify with him and how to explain the coding.


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## marvelh (Apr 6, 2015)

The procedure title is somewhat confusing in that it appears to describe the RF needle placement locations - _*TARGET SITES*: T1, T2, T3, and T4 Bilateral_, not the specific medial branches.  In this case, 4 RF needle placements provides neurolytic destruction to 3 paravertebral facet joints.

Procedure #1 = 3 levels or 64633 - 50  x 1 and 64634 - 50 x 2
C8 and T1 medial branches innervate T1-T2
T1 and T2 medial branches innervate T2-T3
T2 and T3 medial branches innervate T3-T4

C8 medial branch is accessed at the T1 vertebrae
T1 medial branch is accessed at the T2 vertebrae
T2 medial branch is accessed at the T3 vertebrae
T3 medial branch is accessed at the T4 vertebrae

In order to have denervated the C7-T1 facet joint the provider would have also had to place a RF needle at C7 vertebrae which was not documented.

The change in nomenclature is because there is a C8 spinal nerve, hence C8 medial branch but no C8 vertebrae.


Procedure #2 = _*TARGET SITES*: L3, L4, L5 AND SACRAL ALA_ = 3 paravetebral facet joints or 64635 - LT x 1 and 64636 - LT x 2

L2 and L3 medial branches innervate the L3-L4 facet joint
L3 and L4 medial branches innervate the L4-L5 facet joint
L4 medial branch and L5 dorsal ramus innervate the L5-S1 facet joint

L2 medial branch is accessed at the L3 vertebrae
L3 medial branch is accessed at the L4 vertebrae
L4 medial branch is accessed at the L5 vertebrae
L5 dorsal ramus is accessed at the sacral ala


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