Radiology Coding Alert

Request spot-on documentation of time to improve coverage chances.

Does your interventional radiologist 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: UHC 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 thermal radiofrequency ablation (RFA) to treat spinal pain must clearly document six items:

• Procedure's temperature of administration
• Ablation duration
• Side and level of medial branch blocks
• Side and level of specific cervical, thoracic, and/or lumbar ablated
• Percentage of pain relief from prior ablation (if applicable)
• Duration of improvement from prior ablation (if applicable).

"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," states the May 2011 UHC Network Bulletin describing the policy.

Details: UHC's revised coverage criteria add that the patient must have a confirmed positive response to the medial branch block injection at the side and level of the proposed ablation. The revised criteria also require ablation duration to be 40 to 90 seconds.

Documentation additionally must show a temperature of 60 degrees Celsius or more, and it must include confirmation of needle placement using fluoroscopic guided imaging.

Frequency and results: UHC and many other payers agree that thermal RFA 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

Once your provider documents each detail of the procedure, you'll need to code accurately for correct reimbursement.

During thermal RFA, 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. CPT® includes four codes for thermal RFA:

• 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)
• 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. Append modifier 50 (Bilateral procedure) when the provider performs a bilateral service.

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."

Information: 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. The UHC policy applies to thermal RFA; UHC considers pulsed RFA and several other techniques unproven for treatment of spinal pain, and therefore won't cover them.