Anesthesia Coding Alert

Hint: Unlisted might be your best bet

Reporting radiofrequency (RF) of the dorsal root ganglion can be tricky because CPT doesn't include a code specifically for it. If carriers are denying your destruction claims, you should evaluate whether you-re submitting the best-fitting code.
 
Some of the most common possibilities coders consider include:

- 64622-64627--Locations and levels for Destruction by neurolytic agent, paravertebral facet joint nerve

- 64640--Destruction by neurolytic agent; other peripheral nerve or branch

- 64999--Unlisted procedure, nervous system.

Before you jump at one of these coding options, study the pros and cons of each to determine which really is the most accurate.

Knowing Anatomy Eliminates Facet Codes

If you-re tempted to report paravertebral facet joint nerve codes 64622-64627 for RF of the dorsal root ganglion, take a closer look at the nerves- structure. The dorsal root ganglion is closer to the spinal cord than the paravertebral facet joint nerve. These are not the same anatomic structures, so coding 64622-64627 for RF of the dorsal root ganglion is incorrect.
 
Why coders choose it: -These are valid codes and are easy to report and to be reimbursed for,- says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. -You have reasonable diagnoses to support medical necessity and don't have to send extra documentation with the claim.-

But easy coding doesn't always correspond with correct coding.
 
The problem: -Per CPT instructions, the codes you submit can't merely approximate the service provided--they need to match the service,- Hammer explains. -The dorsal ganglion root is not the same structure described by these codes. If you report these codes, you-re not being compliant.-

Superbill pitfall: The coders who report this procedure with 64622-64627 probably do not see RF of the dorsal root ganglion very often, says Myriam Nieves, CPC, ACS-PM, owner of the consulting firm Precision Medical Systems in Ft. Lauderdale, Fla. -This also can be particularly true for coders who mostly code from superbills or encounter forms,- she adds. -The superbill code descriptions often are condensed by removing the -paravertebral facet joint nerve- wording and therefore might be misused.-

Check Your Definition of -Peripheral-

Many coders believe 64640 is appropriate for reporting RF of the sacroiliac joint, and consequently think it should work for RF of the dorsal root ganglion because of its nearby location. But does it really apply?

The answer depends on your provider's opinion of the term -peripheral.-

Stedman Medical Dictionary's definition of peripheral states, -Situated near the periphery of an organ or part of the body in relation to a specific reference point.- Periphery is defined as, -The part of a body away from the center; the outer part or surface.-

Why coders choose it: The dorsal root ganglion is immediately off the spinal cord. Some coders (and providers) believe that qualifies as -peripheral,- so 64640 might be a logical coding choice. Reporting 64640 for RF of the dorsal ganglion root is more compliant than a code from the 64622-64627 series. If your group is audited, Hammer believes you could make a reasonable, rational explanation for why you use 64640 for these procedures. Claims go through the process smoothly if the physician reports a limited number of injections, but submitting 64640 for RF of the dorsal root ganglion does have some issues worth considering.

Problem 1: -If the physician treats more than two spinal levels during a session, the carrier might question the services and request documentation,- Hammer warns. -Carriers tend to think of multiple units of 64640 as -separate and distinct- peripheral nerves rather than additional spinal levels as with paravertebral facet joint destruction add-on codes.-

Problem 2: Some physicians believe that the work involved in locating the dorsal root ganglion is more painstaking and that the potential risks of injury are higher than 64640 represents, Nieves says.

Example: If your physician performs the procedure in the office and you report 64640, the non-facility RVU is 7.22. A single-level lumbar facet joint nerve destruction (64622, Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) carries a non-facility RVU of 10.97. Many physicians believe 10.97 RVUs is more in line with what they do during RF of the dorsal root ganglion.
 
Confirm definitions: Before reporting 64640, discuss the definition of -central nervous system- with your physician. -The basic definition is the brain and spinal cord, which means you could consider all other nerve structures to be peripheral,- says Hammer. The Peripheral Nerve Society considers the dorsal root ganglion to be part of the peripheral nervous system, says Nieves, which bolsters the thinking that reporting 64640 for the procedure would be appropriate.
 
Some physicians shy away from this perspective, believing that the dorsal root ganglion is too close to the spinal cord to be considered -peripheral.-

Bottom line: -If the provider feels comfortable with using 64640 for the RF of the dorsal root ganglion, the coder will be more inclined to use it,- Nieves reasons. It might not be your best option from a -pure coding- standpoint, but it is reasonable and compliant.

Your Best Option Lies With -Unlisted-

Coders often try to steer clear of unlisted procedure codes for a variety of reasons. These catchall codes don't describe procedures very accurately, you need extra documentation to explain the service and assist with claims processing, and reimbursement is uncertain because unlisted codes do not have set RVUs.

But when nothing else seems to fit--as with RF of the dorsal root ganglion--your best option probably is unlisted code 64999.

Why coders choose it: Reporting 64999 is a good option if the physician doesn't feel comfortable coding RF of the dorsal root ganglion as a peripheral nerve, Nieves says. Submitting 64999 along with an explanation of your services and fee also is more compliant than using the 64622-64627 series, Hammer adds. And because you suggest an appropriate fee for the services provided, you might actually receive higher reimbursement for an unlisted code.

The problem: It takes more time--and more work--on your part to get claims paid when you submit unlisted codes for procedures. -Talk to your providers and make sure their operative notes include a statement on the medical necessity, efficacy, frequency and expected outcome of the procedure,- Nieves recommends. -Always include the operative notes and other documentation with your claim.-

Tip: If you expect to report an unlisted code, Hammer advises that you always verify before performing the procedure that the carrier will pay for it. Also confirm how you should submit the unlisted code claim to that particular carrier. Example: Many carriers, such as Noridian Medicare in Colorado, Arizona and other western states, are driving electronic submissions. These carriers want you to file electronically and wait for their request for documentation instead of submitting a paper claim up front with supporting paperwork.
 
Back to basics: -Sometimes coders forget that codes are not just used for getting paid--they need to accurately reflect the service provided,- Hammer states. -How will we ever get new codes if we keep reporting incorrect codes instead of unlisted codes with documentation explaining the service? Reporting unlisted codes is the first step in getting new codes for services.-