Anesthesia Coding Alert

Increasingly, pain specialists use radiofrequency (RF) to treat patients with intractable lower back pain. Various CPT codes may be used to describe the treatment, depending on the nerve destroyed by this technique, which is typically performed in the outpatient setting.
 
Although CPT lists several codes that may be used to report this treatment (or any other technique that involves nerve destruction), RF may also be performed on several nerves, such as the ganglion lumbar nerve, that are not described by existing codes.
 
In such cases, coders may need to use either: (1) a general code that describes the destruction of other peripheral nerves; or (2) an unlisted code, for RF treatments that involve other nerves or no nerves.

What Is Radiofrequency?

Radiofrequency is often used to denervate the facet nerve. This treatment (also known as facet neurotomy, facet rhizotomy or articular rhizolysis) relieves pain caused by degenerative changes in the posterior lumbar facet joints that cause lower back pain (that may radiate to the leg). RF facet denervation can stop the pain, and is often more effective than other neurolytic (nerve-destroying) agents, such as phenol, alcohol and hypertonic saline, because it lasts longer and does not diffuse randomly. The treatment may be indicated if facet joint or median branch injections relieve the patient's pain. RF techniques involve the use of fluoroscopy to position an electrode through which heat or electrical current passes, destroying nearby tissue.
 
Although radiofrequency techniques are used increasingly for therapeutic pain management, they remain a last-resort treatment for patients with certain conditions, such as lumbar spondylosis, when less drastic treatments such as lumbar epidurals or facet injections do not achieve the desired effect, says Lisa Clifford, CPC, a pain-management coding and reimbursement specialist in Naples, Fla.
 
Other conditions that may warrant radiofrequency lesioning include:
 

medial branch nerves for facet pain
 

L2-DRG (dorsal root ganglion) lesions
 

diskogenic pain
 

selective DRGs for radicular pain
 

gray-ramus commuicante lesions for vertebral body compression fractures/lesions
 

sympathetic ganglia for chronic regional pain syndrome (CRPS) Types I and II
 

celiac plexus lesions for intra-abdominal pathology treatment of cervicogenic headaches with cervical medial branch nerve lesions
 

cervical DRG lesions
 

sphenopalatine ganglion, gaussian ganglion and/or trigeminal branch lesions for selective head and neck pain syndromes
 

spinal stenosis.

The treatments deliver a pulsed or heat lesion via a generator that is programmed for the appropriate radiofrequency cannula (tube). Two pulsed lesions of 120-second duration at 42 degrees Celsius typically are applied at each site. If a heat lesion is delivered, a temperature of 80 to 90 degrees Celsius is maintained for one to five minutes, depending on the type of lesion made and the location of the affected nerve.
 
Consider, for example, a female patient with a preoperative diagnosis of cervicogenic headache discomfort. Based on an earlier visit during which the patient experienced significant headache-pain reduction following diagnostic right upper cervical medial-branch nerve blocks, the physician decides to perform pulsed radiofrequency lesioning at the right C2-3, C3-4 and C4-5 medial branch nerves.
 
During the treatment, the patient's C2-3, C3-4 and C4-5 medial-branch nerve regions are isolated in the right cervical spine using fluoroscopy. Lidocaine is locally infiltrated over each of these levels, followed by the introduction of a radiofrequency cannula, which delivers a pulsed radiofrequency lesion for 120 seconds. The procedure is repeated for the C3-4 and C4-5 nerves, also under fluoroscopic guidance.

Coding the Procedure

Amy Mowles, a pain-management coding and reimbursement specialist in Bowie, Md., says to code the procedure above in the following way:
 

64626 destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level

64627 cervical or thoracic, each additional level (list separately in addition to code for primary procedure)
 

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.

Note: Some carriers may prefer that 64627 be listed once, with a 2""" in the units box.
 
The coding for the scenario described above is relatively straightforward because CPT includes a code for destruction of the nerves of the facet joint. CPT includes other codes that apply to destruction of specific nerves" such as:
 

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)

64640 other peripheral nerve or branch.

The codes' subsection (destruction by neurolytic agent [e.g. chemical thermal electrical radiofrequency or chemodenervation]) makes it clear that code selection is not determined by the technique used Mowles notes adding that the location of the specific nerve or branch is the key factor in the choice of code used.
 
Unlike the nerve-block codes (64400-64484) which include a long list of nerves there are no codes to report RF (or any other method of nerve destruction) for nerves other than the facets and intercostals. Although 64640 should be used to report ""other peripheral nerves or branches "" the destruction may not have involved a peripheral nerve or for that matter any nerve Mowles says.
 
If for example a dorsal root ganglion is destroyed by radiofrequency (or any other method) unlisted code 64999 (unlisted procedure nervous system) should be used to report the treatment Mowles says. She adds that although using an unlisted code requires manual review and clear and accurate documentation of the treatment it allows the physician to bill the procedure at an amount commensurate with the work performed instead of following the fee schedule which assigns only 7.43 transitioned non-facility relative value units (RVUs) to 64640.

Add-on Codes Modifiers and Fluoroscopy

There is no payment adjustment for 64623 or 64627 as these ""add-on"" codes (which never should be billed unless 64622 and 64626 respectively are also billed) are already reduced. Therefore payment should be 100 percent of the fee scheduled amount for each level billed. Additional treatments performed on other nerves by the same provider will be reduced by 50 percent.
 
Bilateral services for 64622/3 and 64626/7 may be billed by appending modifier -50 (bilateral procedure) to the appropriate code. Carriers may have their own restrictions however; for example Medicare carriers may require additional separate access to the second (bilateral) area before considering additional reimbursement for bilateral procedures Mowles says. The physician may be required to use modifiers -LT (left side) and -RT (right side) rather than modifier -50.
 
This should not preclude payment. In Florida the Part B carrier First Coast will pay 150 percent for bilateral treatments of initial and additional vessels (i.e. 64622-50 and 64623-50) Clifford notes.
 
However the Medicare fee schedule does not automatically permit bilateral billing for 64640 or 64999. These claims are decided by carrier preference on a case-by-case basis.
 
Modifier -26 (professional component) is frequently used when billing these treatments. If the fluoroscopy used to guide the radiofrequency treatment is not owned by the pain physician or his or her practice modifier -26 must be appended to indicate that only the professional services should be paid.
 
Most managed care and Blue Cross/Blue Shield plans reimburse such professional services at or close to the Medicare rate (0.82 RVUs versus 2.18 RVUs if the physician or the practice owns the fluoroscopy equipment).

Medical Necessity and Diagnosis Coding

Although most carriers cover radiofrequency treatment of vertebral nerves certain conditions must be met before payment for the treatment is approved. For example Aetna U.S. Healthcare pays for RF only when all of the following are met: Note: Aetna permits one RF treatment per year.

Patient has experienced severe pain limiting activities of daily living for at least six months.
 

Patient has had no prior spinal fusion surgery.
 

Neuroradiologic studies are negative or fail to confirm disk herniation.
 

Patient has no significant narrowing of the vertebral canal or spinal instability requiring surgery.
 

Patient has tried and failed conservative treatments such as bed rest back supports physiotherapy correction of postural abnormality as well as pharmacotherapies (e.g. anti-inflammatory agents analgesics and muscle relaxants).
 

Trial of facet joint injections has been successful in relieving the pain.
 
Any RF code that is billed must be linked to an appropriate diagnosis code. It is helpful Mowles says to obtain lists of acceptable ICD-9 codes from payers particularly if an appeal for non-payment has to be filed.
 
The following list includes some diagnosis codes that may be acceptable for RF procedures:
 

722.0 cervical disc displacement
 

722.4 cervical degenerative disc disease
 

722.52 lumbosacral degenerative disc disease
 

722.81  cervical postlaminectomy syndrome  lumbar postlaminectomy syndrome

723.0 cervical stenosis
 

723.4 cervicobrachial radiculitis
 

724.02 lumbar stenosis
 

724.2 low back syndrome.