Anesthesia Coding Alert

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Steer Clear of These Traps When You're Reporting SI Joint Radiofrequency

Published on Sun Aug 21, 2005

Hint: Location is key when determining correct codes

"Performed radiofrequency (RF) to the patient's sacroiliac joint" on a patient's chart may sound like solid documentation, but when you encounter this phrase on your next chart, be sure to check these important missing details before you begin coding.

Verify If the Physician Treats the SI Joint or Nerves

Your first step toward correct coding is to verify whether the physician performed the destruction within the SI joint itself or to the nerves that innervate the SI joint. Chances are, you'll be coding for procedures that affect the surrounding nerves.

"The injections often are performed on nerves that derive from the lateral branches of the S1-S3 dorsal rami," explains Myriam Nieves, CPC, ASC-PM, director of coding and reimbursement for Axis Management and Billing Services in Hollywood, Fla. "Therefore, the provider's documentation will most probably state that 'Motor stimulation was performed at the SIJ medial branch nerves.'"

Many coders rely on codes 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) or CPT 64623 (... lumbar or sacral, each additional level [List separately in addition to code for primary procedure]) for these injections, but that can be a mistake. Some basic knowledge of anatomy helps to show why:

Reason 1: The paravertebral facet joint nerves don't innervate the SI joint. Nieves believes that coders usually get confused because the descriptors of 64622 and 64623 read "lumbar or sacral." Coders who are not familiar with anatomy might think this justifies an injection in the sacroiliac joint.

Reason 2: There are no paravertebral facet joints below the L5-S1 facet joint. Providers often perform destruction of some branches that innervate the SI joint (such as L5, S1, S2 and S3). These are not paravertebral facet joint nerves, so coding it as such is incorrect.

Report RF More Accurately with 64640 or 64999

So, if 64622 and 64623 aren't accurate for reporting RF of the nerves surrounding the SI joint, what's your best option? Many coders tend to agree that you have two viable alternatives, depending on the situation: 64640 (Destruction by neurolytic agent; other peripheral nerve or branch) or an unlisted code, such as 64999 (Unlisted procedure, nervous system).

"I believe that 64640 could be a good choice for injecting the nerves around the SI joint," Nieves says. "Technically, a peripheral nerve is a nerve located outside of the brain and spinal cord, so it would be correct to classify these nerves as 'peripheral' nerves or branches."

Some providers are not comfortable reporting 64640, either due to the description (they want something more specific) or due to the RVU valuation. They choose to use 64999 (Unlisted procedure, nervous system) instead.

Each option has its pros and cons:

64640 - Pro: Code 64640 has a set RVU of 10, which means payment will be processed easily compared to an unlisted code. Con: The RVU may not fully reflect the extra work that injecting the nerves around the SI joint involves. These nerves are extremely small and are difficult to locate and inject. The provider often needs to administer multiple injections to improve the odds of denervating the source of the pain.

64999 - Pro: Unlisted codes do not have a set RVU, so most carriers will pay a percentage of the billed charges. Because of the difficulty of the procedure, carriers often reimburse a higher amount for 64999 than for 64640. Con: Using an unlisted code requires more work from the billing staff, since you must send the carrier a letter describing the procedure performed and the CPT code that it is comparable to. If the carrier denies the first submission, you need to submit a letter from the physician indicating medical necessity. An unlisted procedure code also takes more time for the carrier to process, which impacts the group's cash flow.

Consider 22899 for Unspecified Nerve Sites

Ideally, the provider documents the procedure clearly enough for you to understand which nerves were treated. If the provider performs radiofrequency to multiple sites within the SI joint capsule without documenting specific nerves, consider reporting 22899 (Unlisted procedure, spine) instead of 64499.

Checkpoint: Verify information with the provider before submitting 22899. "If no nerves are identified, request further clarification from the provider," Nieves advises. "Most of the time the provider performs radiofrequency on the nerves, which means 64999 would be a more appropriate code."

Complete the Claim with Fluoro, Bilateral Details

Remember two final details before completing your RF claim: fluoroscopic guidance and unilateral versus bilateral injections.

Physicians often use fluoroscopy for localization before performing RF. If you're coding the procedure with 64640, report fluoroscopy with 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]). Some physicians also perform an SI joint arthrogram for diagnostic purposes, says Robin Fuqua, CPIC, a coder for Jose Veliz, MD, at Palomar Pain Management Center in Escondido, Calif. Report the arthrogram with 73542 (Radiologic examination, sacroiliac joint arthrography, radiological supervision and interpretation). Take note: The fluoroscopy is bundled with the procedure, so you don't report it in addition to the arthrogram.

If the physician adds dye and actually looks at diagnosing a joint and writing a formal report of that joint, then it is an arthrogram. Many carriers will not pay for fluoroscopy or an arthrogram if you bill it with an unlisted code; be sure you appeal the decision and that everything is documented in the notes. Also, remember to fill in Box 19 of the HCFA form with a description of the unlisted code to help the claims process go more smoothly.

If the patient complains of bilateral pain, the physician might administer injections on both sides during the same session. If you're reporting the procedure with 64640, coders differ in their opinions of which modifier best describes the situation.
"Injection procedures are typically coded as individual injections," explains Fuqua. "Left, right, high, low - it doesn't matter. Each injection is considered to be independent of the other, so coding with modifier 59 (Distinct procedural service) signifies that you performed the identical injection somewhere else. It doesn't matter where else it was performed, just that it was done again and was the same injection as the first."

Some other coders don't believe using modifier 59 is appropriate for these cases. Instead, they recommend using either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side) as different line items. Check to see which modifiers the carrier you are submitting the claim to prefers.

Ensuring that the physician has fully documented the procedure properly can be the biggest challenge when coding for radiofrequency of the SI joint. But by understanding the joint and nerve anatomy, reading the documentation carefully and paying attention to details, you can submit clean claims.