# Help with 64640



## mbort

ok all of my spine FRIENDS!!  I need help.  I have a provider challenging my coding.  

Would you code the following with 64640 x1 or 64640 x9??
Can you provide me written documentation for your answer for either scenario?

POSTOPERATIVE DIAGNOSES:  1.         Chronic low back pain.
                                          2.         Lumbar degenerative disc disease.
                                          3.         Lumbar herniated nucleus pulposus.
                                          4.         Sacroiliac dysfunction, recurrent.
                                          5.         Lumbar postlaminectomy syndrome.

PROCEDURE PERFORMED:                    Radiofrequency denervation of left sacroiliac joint under fluoroscopic guidance.
ANESTHESIA:                                              MAC.

DESCRIPTION OF PROCEDURE:            The patient was greeted in the OR holding area where consent was verified for today's procedure and his NPO status was confirmed.  The procedure site and side was verified and marked with the patient's participation.  An intravenous line was started.  He was premedicated with Ancef 1 g IV just prior to the procedure.  He was then transported to the operating room where he was positioned prone on the x-ray table with appropriate padding.  A time-out was taken and monitored anesthesia care was administered by Dr. XXX.  The Cosman radiofrequency lesion generation system was prepared for use.  A grounding pad was connected to the patient's left lateral thigh.  All lesions described in this operative report were generated using 100-mm curved cannulae with the appropriate size electrodes.  Prior to all lesion degeneration, there was careful fluoroscopic confirmation of cannula position.  Also, continuous impedance monitoring was utilized.  The impedance was ranged from 150 to 220 ohms.  Prior to lesion generation, motor stimulation was performed at 2 hertz upto 3 volts and at no time there was left lower extremity motor stimulation observed.  All lesions described in this operative report were generated to the target temperature of 85 degree celsius for a lesion time of 90 seconds.  The left gluteal area was thoroughly prepared with ChloraPrep and draped in the usual sterile fashion.

Using fluoroscopic views in the AP, oblique, and cephalad angulated projections, the left sacroiliac joint was optimally visualized.  The skin entry points were selected overlying the structure and 1% Xylocaine was infiltrated into the skin and subcutaneous tissues for local anesthesia.  Under fluoroscopic guidance, a total of nine 100-mm radiofrequency cannulae were directed until the needle tip entered the articular portion of the joint.  The cannulae were arranged in strip fashion.  After careful fluoroscopic conformation of cannula position and negative motor stimulation, lesions were generated based on the above-described parameters.  All cannulae were then removed.  There was adequate hemostasis noted at the skin puncture sites.  The patient's vital signs remained stable.  He was able to move all four extremities following the procedure.  He was transported to the recovery room in satisfactory condition.


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## PatriciaCPC

Just once... 
See page 1 / #9 - hopefully this helps!
http://www.dentox.com/pages/handouts/BTX BILLING CODES.pdf


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## mbort

pdelorenzo said:


> Just once...
> See page 1 / #9 - hopefully this helps!
> http://www.dentox.com/pages/handouts/BTX BILLING CODES.pdf



Thanks Patricia.  Thats how I coded it but they want me to code it x9 since that is what the surgeon is reporting.  I dont think the documentation supports it and I also don't think its possible..but I need to prove it.  

Thanks also for the link, since that talks more about Botox injections (even though its the same code) do you have anything else that I could use?  This administrator at the ASC is a BEAR and I know that that documentation won't fly for "radiofrequency".

Thanks in advance for any other help anyone can give me!!
Mary, CPC,CPC-ORTHO


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## RebeccaWoodward*

Mary,

I originally thought 1 but then I found some other literature.  I'm second guessing myself, now.

64640 Units Per DOS
How many times can CPT code 64640 (Destruction by neurolytic agent; other peripheral nerve or branch) be charged per date of service? 
RECOMMENDATION: Typically only expect to see one unit only submitted. However, if billing multiple services, Medica and UCare accept multiple units. Other payers require multiple lines with the -76 modifier.

http://www.health.state.mn.us/auc/hcpcsclosed2006.pdf                page 13

_*My Medicare carrier*_--  "Unless multiple sites are treated, the number of services should be no more than one per date of service"

Now...take a look at sample 3 on this web site...

http://www.justmypassion.com/articles-MBC-12.html

So...this appears to be a carrier specific edit??


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## PatriciaCPC

I hear you Mary - Good info Rebecca!!! - Mary - Check out that last link that Rebecca posted... interesting... maybe the carrier/ or the carrier's website would be of help to you??


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## mbort

thanks to both of you for your help on this.  I did see that on that website while I was researching the other night but there is nothing really to support it other than "she did some research".  I would love to find something from CMS or the AMA on this to back it up, otherwise I have to stick with my gut and keep it to just "one" injection.  Unfortunately this is one of my ASC's (in NJ) that I code for so I dont have access to the insurance information although I may request it for this particular scenario.

I feel that only one needle was inserted and then the nine cannulae were placed in a "carpet row" type fashion.  

Do you guys see 9 seperate areas within the SI joint?

ughhhhhh!! 
Thanks again for your input...its greatly appreciated.


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## jdrueppel

Mary,
We no longer have a free standing pain clinic so it's been awhile since I've had to bill the "professional" fees for this type of service.  I've looked all over the Medicare website and web for clarification for billing multiple units of 64640 and was not able to find anything. 
I agree with you that this service should only be billed as "1" unit.  Based on common sense one unilateral service = 1 unit.  If you look at the CPT description "other peripheral nerve or branch" I could see where some carriers erroneously, not fully understanding the scope of service, would allow this to be billed as multiple units based on "multiple" sites.  When this service is done at the lumbar, thoracic, or cervical level it is allowed at only one unit unless bilateral or if additional levels are done then the add on code is necessary for payment.  Also, the Medicare physician fee schedule appears to be valuing this code based on the "1" unit theory.
Unfortunately, this probably won't satisfy the practice administrator.  It may be necessary to get the payer information for this particular charge to query their specific interpretation of billing guidelines for this CPT code.
Julie, CPC


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## PatriciaCPC

Just logged in today for the first time in a week - going to look for more info...


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## Larmour

*64640 Medicare*

Hi All,
Have been having a hard time finding Medicare documentation as to allowed units for CPT 64640. Calling Massachusetts Medicare Provider Relations I was told that Medicare allows up to 4 units, 1 per a line and use 59 modifier on second, third and fourth. I was given a route through the Medicare cms.hhs.gov to get documentation but failed miserably. This does however confirm what was already said in previous response. If anyone has gotten any formal documentation please let me know. 
Thanks,
Lise
MGH 
Boston, MA


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