Anesthesia Coding Alert

Question: I’ve read that we should report 64999 for radiofrequency of the lumbar sympathetic chain, but one of our physicians insists that we should code with 64640. What’s the correct approach?

West Virginia Subscriber 

Answer: CPT® currently does not include a code that represents radiofrequency destruction of the lumbar sympathetic chain. Because of this, the information you’ve read is correct: Submit 64999 (Unlisted procedure, nervous system). It can be difficult to get paid for “unlisted” codes, so drop the claim to paper and submit it with dictation and supporting documentation explaining the procedure.

Background: The CPT® codebook separates the Destruction by Neurolytic Agent procedures into two sections: Somatic Nerves and Sympathetic Nerves. The somatic nervous system is made up of nerves that connect to the skin, sensory organs and all skeletal muscles. The system is responsible for nearly all voluntary muscle movement as well as processing sensory information that arrives via external stimuli including hearing, touch, and sight. Note that code 64640 (Destruction by neurolytic agent; other peripheral nerve or branch) is included under the somatic nerves section.

In contrast, the sympathetic nerve system is a primitive alternate nervous system that is considered to be usually outside our conscious control. It controls the amount of blood going through the arteries, the heart rate, breathing rate, etc. The lumbar sympathetic chain is found anteriorly to the L2, L3, and L4 vertebral bodies with communication to the thighs, legs and feet. The sympathetic nervous system potentially is involved in some pain conditions such as complex regional pain syndrome, formerly known as reflex sympathetic dystrophy (337.2x, Disorders of the autonomic nervous system; reflex sympathetic dystrophy).

Reviewing the CPT® code options in the Sympathetic Nerves section, note there is no listing specifically for lumbar sympathetic, only celiac plexus and superior hypogastric plexus. CPT® directs providers to “Select the name of the procedure or service that accurately identifies the service performed. Do not select a procedure code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code...”