Neurosurgery Coding Alert

This payer wants to see you report 77003 separately.

If your practice participates with United HealthCare (UHC), you'll want to take note of UHC's recent policy update (number 2010T0107H) on ablative treatment of spinal pain. Although UHC has a limited coverage policy for a number of spinal pain and facet joint pain procedures (64622-64627), you have some chance of reimbursement if you know the rules.

Ablation Method and Frequency Matter

Among the changes are a revised coverage policy for how often thermal radiofrequency ablation (RFA) can be performed and reimbursed. The policy states that thermal RFA is covered "when performed at three months or greater frequency, provided there has been a 50% or greater documented reduction in pain."

Example: On May 15, 2010, the physician performs a repeat thermal radiofrequency (RF) ablation on the right L4 and L5 paravertebral facet joint nerves on a patient with right lumbar facet joint pain. You would report codes 64622 (Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level) and +64623 (... lumbar or sacral, each additional level [List separately in addition to code for primary procedure]).

The catch: The last thermal RF ablation on those same facet joint nerves needs to have been performed prior to February 15, 2010 (at least a three-month period), to meet the UHC policy criteria. The physician's notes would also need to indicate that the patient experienced at least a 50 percent reduction in pain following their previous thermal RF ablation, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Colo.

Reimbursement Tough for Thermal RF Treatment

UHC's policy toward thermal radiofrequency ablation can seem disheartening at first glance. The policy's coverage rationale points out a number of conditions for which treatment for spinal or orthopedic pain is not covered, including:

Bright side: Standard applications of thermal radiofrequency are covered, says Dawn Shanahan, CPC, supervisor of coding with FGTBA in Tampa, Fla. For example, UHC coverage rationale states that thermal radiofrequency ablation for chronic cervical, thoracic, and lower back pain is covered, when confirmed by a medial branch block injection (64490-64495, Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT]...).

"You must show that their guidelines have been met in your medical records," Shanahan says.

Fluoroscopic Guidance Required

One such guideline is the necessity of fluoroscopic guidance (77003, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) when a physician performs these procedures.

The image guidance requirement makes sense, Hammer says. "Per medical care standards, providers should not perform the thermal destruction procedures 'blind' or 'anatomically guided.'"

Pulsed Radiofrequency, Other Ablations Not Covered

Practices that use emerging techniques to treat chronic spinal pain will also be in for some disappointments. The updated UHC policy considers pulsed RF therapy, cryoablation, alcohol ablation, and laser ablation to be unproven for spinal/facet joint pain and, therefore, not covered.

But the coverage climate could be changing. "If future studies demonstrate the safety and efficacy of alternative methods of destructive neurolysis, it is possible that third-party payers may reconsider their non-coverage decision, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison."The rapid growth of these types of procedures using a variety of methods is leading more payers to examine the published medical evidence for a particular method, with subsequent revision of prior coverage policies."

If your practice uses pulsed radiofrequency ablation you will need to turn to an unlisted code. UHC points specifically to pulsed RFA and instructs you to report 64999 (Unlisted procedure, nervous system).

Reasoning: "Some people will try to bill the pulsed RFA using the normal CPT codes used for thermal RFA," Shanahan says. The policy is "stating it should be an unlisted code, and they do not cover it," she adds.

The CPT manual also sets the following guideline in the "Destruction by Neurolytic Agent" section: "For therapies that are not destructive for the target nerve (e.g., pulsed radiofrequency), use 64999." A CPT Assistant article from August 2005 echoes that, suggesting you use 64999 when pulsed radiofrequency is performed on any anatomic region and on any nerve. "Research at the time observed that pulsed radiofrequency treatment did not result in anatomical destruction, thus precluding use of the existing neurolytic codes," adds Przybylski.