Neurology & Pain Management Coding Alert

Check that your providers have clear documentation for these critical areas.

Does your pain management specialist clearly document each detail of ablation treatments for spinal pain, from the temperature and duration to the level of improvement? He needs to, if you file claims with United Healthcare (UHC).

Explanation: United Healthcare introduced revised guidelines for "Ablative Treatment for Spinal Pain," effective for treatments provided on June 1, 2011, and beyond. The guidelines specifically address six areas where clear documentation is imperative, so work with your providers to ensure their documentation passes muster.

Focus on Temperature, Duration, and Location

The UHC policy states that medical records for ablation to treat spinal pain must clearly document six items:

• Temperature of administration of procedure
• Duration of ablation
• Specific identification of side and level of medial branch blocks
• Specific cervical, thoracic and/or lumbar ablated by side and level
• Percentage of pain relief with prior ablation, if applicable
• Duration of improvement from previous ablation, if applicable.

The policy further states, "If the original medical records do not document this level of detail, we will accept submissions with medical record addendums with the required information. Upon review of the required clinical documentation, a coverage determination will be provided."

Details: The patient must have a confirmed positive response to the medial branch block injection at the side and level of the proposed ablation. Thermal radiofrequency ablation must be administered at a temperature of greater than 60 degrees Celsius; ablation duration must last 40 to 90 seconds; and must include confirmation of needle placement using fluoroscopic guided imaging.

Treatment times: UHC and many other payers agree that thermal radiofrequency ablation treatments should occur at least six months apart, with a maximum of two treatments over a 12-month period. Physicians should also be able to document that the patient experienced a 50 percent or greater reduction in pain for 10 to 12 weeks.

"Providers need to also be watchful of the utilization guidelines in the Medicare LCDs regarding radiofrequency ablation," says Leslie Johnson, CCS-P, CPC, manager of coding, compliance, and education at Somnia, Inc. in New Rochelle, N.Y. "There are guidelines for how often and under what circumstances these destructive procedures can be done. It's important to understand and follow these utilization guidelines -- along with the documentation requirements in the LCD coverage policies -- because they are the same policies that UHC seems to lean toward as 'standard of care.'"

Help the Cause by Coding Correctly

Even if your provider documents each detail of the procedure, you need to code accurately for correct reimbursement.

Differences: Your provider can choose between two types of radiofrequency ablation. During thermal radiofrequency ablation, the physician places a needle or electrode percutaneously and administers a 40- to 90-second current that destroys the paravertebral facet joint nerves (also known as the medial branch and/or dorsal ramus). Paravertebral joint nerves provide sensory innervation from the facet joint. In pulsed radiofrequency ablation, the provider delivers multiple bursts of current that are shorter and of lower temperature, just above normal body temperature, than with the thermal technique. Pulsed RFA might cause fewer side effects, but hasn't been studied in long-term clinical trials. CPT® includes four codes for thermal RFA:

• 64622 -- Destruction of 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 -- 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).

Choose your code (or codes) based on the anatomic spinal region of the destructive treatment and the number of levels treated. Include modifier 50 (Bilateral procedure) when applicable.

In addition, you'll report fluoroscopic guidance with 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction).

Heads up: "Even though fluoroscopic needle guidance is bundled into facet joint injections, it is not bundled into the paravertebral facet joint destruction codes," notes Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. "Some practices made the wrong assumption that they couldn't  bill for both procedures on these nerves."

Pulse change: CPT® does not include a code that accurately describes the pulsed technique. When your provider treats a patient with pulsed RFA, you'll submit 64999 (Unlisted procedure, nervous system). "Provider documentation should be similar to the UHC requirements, including the temperature, duration, and mode of radiofrequency ablation," Hammer says. Many providers use codes 64622-64627 (Destruction by neurolytic agent, paravertebral facet joint nerve ...) as a  basis for valuation.

Information: Note that the UHC policy applies to thermal RFA; United Healthcare considers pulsed RFA (and several other techniques) as unproven for treatment of spinal pain. You'll find the revised medical policy (Ablative Treatment for Spinal Pain) at www.UnitedHealthcareOnline.com. Follow the links from Tools and Resources to Policies and Protocols, then Medical & Drug Policies and Coverage Determination Guidelines.