Anesthesia Coding Alert

Correct coding for radiofrequency thermoneurolysis depends on ensuring that the nerve was treated but not permanently destroyed, knowing what nerve was treated, and not letting the CPT index trip you up when searching for appropriate codes.

Anesthesia providers use radiofrequency neurolysis also known as rhizotomy, RF denervation, radiofrequency thermoneurolysis and other names to temporarily destroy nerves to relieve pain.

Verify That the Nerve Was Treated But Not Destroyed

If the doctor continuously applies high-frequency energy to a patient's nerve tissue, the nerve heats up to more than 65 degrees Celsius, which is enough to destroy conduction through that nerve (known as thermocoagulation radiofrequency). If the physician delivers the energy as intermittent pulses (known as pulsed radiofrequency), signal conduction along the nerve is still interrupted for three to 18 months even though the tissue barely heats. This technique appears to produce longer-lasting pain relief than chemical nerve blocks, without the risk of the chemical spreading to areas not targeted for treatment. Physicians often use pulsed RF to treat peripheral nerves without a myelin sheath, such as those to facet joints (nonmyelinated nerves respond better to this type of treatment). Sympathetic nerves also respond well to RF treatments.

Every patient who undergoes RF neurolysis may not experience total pain relief, and pain may recur or even worsen (known as anesthesia dolorosa). Because of this, physicians often use RF neurolysis as a last resort for treating chronic pain that has not responded well to other therapies. These conditions include intractable back pain (724.x, Other and unspecified disorders of back), facial pain (350.2, Trigeminal nerve disorders; atypical face pain; or 351.8, Facial nerve disorders; other facial nerve disorders), headache (784.0, Symptoms involving head and neck; headache), chest wall pain (786.52, Chest pain; painful respiration), or neck (723.1, Other disorders of cervical region; cervicalgia), arm (729.5, Other disorders of soft tissues; pain in limb) and shoulder (719.41, Other and unspecified disorders of joint; pain in joint; shoulder region) pain.

For coding, you need to ensure that the doctor treated the nerve and relieved the patient's pain, but that he or she did not destroy the nerve. "Using the pulse technique is a lot like dimming a lightbulb instead of switching it off completely," says Robin Fuqua, CPIC, a coder with Jose Feliz, MD, Inc. in Escondido, Calif. "It's a lot healthier for the patient than completely destroying the nerve."

Code All Parts of the Procedure

Some physicians precede RF procedures with a diagnostic block to ensure that the patient has at least 50 percent pain reduction once the physician injects a local anesthetic to the area. The practitioner normally performs the diagnostic block and therapeutic RF procedure at two separate sessions to increase accuracy and ensure that he or she administered the diagnostic block to the correct area and that it worked adequately. The timing of the diagnostic and therapeutic sessions often depends on the patient's and physician's schedules rather than medical need.

According to CPT Lay Descriptions 2002, "Generally, intravenous conscious sedation [during RF neurolysis] is utilized during the initial phase of the procedure so that the patient can assist the physician in identifying the site of pain and the correct placement of the neurolytic agent." Code this part of the procedure with 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). Although some carriers don't reimburse for conscious sedation, you should still code for it to thoroughly document the procedure.

The physician uses fluoroscopy (76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) during the second (therapeutic) phase of  treatment to ensure the correct site is being treated. Once this is verified, he or she administers a local anesthetic to prevent pain from the needle (the fluoroscopy is billable with 76005, but this anesthetic is not because it is included in the procedure itself). Some sedation (99141) is also administered during the procedure itself.

Because the physician usually performs the procedure in two sessions, you should bill it as a staged procedure. Code stage one (the diagnostic block) with 99141 for the conscious sedation and the injection site's appropriate code. Code stage two (the therapeutic treatment) with 76005-99141 and the injection site's code. Append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the second procedure's codes and be sure the report indicates that this was the second stage of the procedure.

Don't Let CPT Lead You Astray

Because radiofrequency neurolysis is known by several different names, a beginning coder or an experienced coder unfamiliar with the procedure may have trouble determining how to code it.

"Radiofrequency neurolysis" and "radiofrequency denervation" aren't in the CPT index. "Rhizotomy" is, but leads you to codes that are for laminectomy (63185, Laminectomy with rhizotomy; one or two segments; and 63190, more than two segments). The reference to "neurolysis" takes you to nerve codes 64704-64708 (which are for neuroplasty instead of neurolysis) and to add-on code +64727 (Internal neurolysis, requiring use of operating microscope [list separately in addition to code for neuroplasty] [Neuroplasty includes external neurolysis]). Basing your report on "denervation" goes to codes 64802-64818 for excision of sympathetic nerves.

"As far as pain management is concerned, we use the codes for destruction by neurolytic agent," says Sharon Ryan, CPC, with Anaesthesia Associates of Massachusetts PC, in Westwood. These include the codes for destruction by neurolytic agent (chemical, thermal, electrical, radiofre-quency or chemodenervation) somatic nerve injection codes 64600-64640, and sympathetic nerve injection code 64680 (Destruction by neurolytic agent, celiac plexus, with or without radiologic monitoring).

Base your coding on the type of nerve, treatment site and injection levels. Somatic nerve options include 64620 (Destruction by neurolytic agent, intercostal nerve), 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level), +64623 ( lumbar or sacral, each additional level [list separately in addition to code for primary procedure]), 64626 ( cervical or thoracic, single level), +64627 ( cervical or thoracic, each additional level [list separately in addition to code for primary procedure]), 64630 (Destruction by neurolytic agent; pudendal nerve) and 64640 ( other peripheral nerve or branch). 64680 is used for sympathetic nerve destruction, as noted above.

These codes all specify nerve destruction, which leads some coders to wonder if they should append modifier -52 (Reduced services) if the nerve is temporarily disabled with the RF pulse technique instead of permanently destroyed. Modifier -52 is not necessary because the anesthesiologist's scope of work remains the same and, for all practical purposes, the nerve is destroyed and function is lost for a prolonged period.