Anesthesia Coding Alert

Hint: Think in terms of joints, not nerves. 

If your physician administers paravertebral facet joint injections, coding for radiofrequency (RF) ablation can be tricky. Destroy your denials – not your reimbursement – by following three steps from Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver, Co.

Step 1: Focus on Joints, Not Nerves

In the past, you coded for destructive procedures based on each individual nerve, as opposed to diagnostic/therapeutic injections that are based on the facet joint level. But that changed when new codes for paravertebral facet joint destruction became effective in 2012.

“At that point the ‘counting’ methodology changed to be similar to the injection codes,” Hammer says.

Explanation: CPT® Changes 2012 explained the reason for the change. “Prior to 2012, the unit of service used to report these procedures was a single nerve at a single vertebral level. However, two nerves innervate each facet joint, and there are two facet joints at each vertebral level. One or two facet joints at the same level potentially could be treated. As such, the vertebral level is of less significance than the number of facet joints treated, so using vertebral level as the unit of service did not adequately reflect the work performed.”

This issue was addressed by specifying the unit of service as a single facet joint in the codes’ descriptors rather than a vertebral level.

Step 2: Know the Joint Designations and Limits

You have four codes to choose between when coding spinal RF ablation, based on the spinal area and number of joints treated in that spinal area:

• 64633 – Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
• +64634 – … cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
• 64635 – … lumbar or sacral, single facet joint
• +64636 – … lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure).

Injection codes are based on first, second, and “third and all additional” levels. The RF ablation codes are similar, with designations for first and “each additional” spinal levels. Remember that you only can report the add-on codes for injections with a maximum of 1 unit of service because of the “third and any additional level(s)” portion of the descriptors. By contrast, the destruction add-on codes note each additional,” which means you can report the destruction add-on code more than once to reflect the provider’s work. There’s no limitation for the destruction codes from a CPT® coding perspective.

Tip 1: The number of nerves injected for a single facet joint does not affect your code selection (because the descriptors indicate “nerve[s]”).

Tip 2: If your physician treats both facet joints at the same vertebral level, report the parent code (64633 or 64635) with modifier 50 (Bilateral procedure) appended.

Caution: Many payers have frequency limitations associated with the destruction procedures. For example, the CGS Part B L34409 information states, ”For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any calendar year, involving no more than four (4) joints per session.”

Step 3: Don’t Confuse Code Order

The code set for paravertebral facet joint destruction is classified as resequenced, meaning the codes are not where they normally would be for numerical order. Instead, they fall between two other neurolytic destruction codes: 64620 (Destruction by neurolytic agent, intercostal nerve) and 64630 (Destruction by neurolytic agent; pudendal nerve)