Radiology Coding Alert

Plus: Verify how each payer wants bilateral procedures reported.

Spinal radiofrequency (RF) coding got a makeover in 2012 with the implementation of new CPT® codes and descriptors. Our experts share the top tips you need to remember to submit accurate claims.

Include Imaging in the New Codes

CPT® 2012 deleted four codes for paravertebral facet joint nerve destruction (64622, +64623, 64626, and +64627). According to AMA's CPT® Changes 2012, "Four new codes have been established to more accurately reflect the work and anatomical site involved in these procedures." Your new code options are:

• 64633, Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
• +64634, ... cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
• 64635, ... lumbar or sacral, single facet joint
• +64636, ... lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure).

Crucial: The change reflects the current clinical practice of performing paravertebral facet joint services with some type of imaging guidance in most cases. As a result, each of the new codes combines injection and imaging guidance. You should not report fluoro or CT imaging guidance separately.

Change Your Counting Perspective

While the 2011 destruction codes addressed levels, codes 64633-+64636 address individual joints.

"Prior to 2012, the unit of service used to report these procedures was a single nerve at a single vertebral level," states the AMA. Take a closer look at 64633-+64636 and you'll see that "The unit of service is a single facet joint ... rather than a vertebral level."

Meaning: Now when you code RF of the paravertebral facet joints, focus on counting joints instead of nerves.

Example: "In 2011, if a physician documented that he performed RF at C3-C6 you would code for C3, C4, C5, and C6 paravertebral facet joint nerve destruction separately for a total of four," says Kyle Shupe, with Medical Billing Inc. in Ankeny, Iowa. These four medial branches provide the sensory innervation to the C3-C4, C4-C5, and C5-C6 paravertebral facet joints. In 2012, the code descriptor reads "single facet joint," so now you report a total of three facet joint levels, which translates to 64633 with one unit of service and +64634 with two units of service.

The same holds true for coding in the lumbar region. If the procedure note indicates RF ablation of the L3 and L4 medial branches and the L5 dorsal ramus, report 64635 with one unit of service and +64636 with one unit of service. These three paravertebral facet joint nerves provide innervation to the L4-L5 and L5-S1 facet joints.

Careful: When coding these injections, verify whether you're reporting anatomic locations of the injections or medial branches. "It can be different scenarios, based on how it's documented," says David Waldman, CPC, CPC-H, with The Headache and Pain Center in Overland Park, Kan. "It can be anatomical location or medial branches, and that can affect which facet levels are being treated."

Watch for Bilateral Opportunities

Note that the code descriptors for 64633-+64636 apply to "nerve(s)." That means a code can represent destruction by either a single nerve injection or multiple injections to that joint. However, if your provider injects bilateral nerves at a single level, you will need to report the service as a bilateral procedure. CPT® intends these new codes to report unilateral procedures.

So if a physician performs RF destruction of the paravertebral facet joint nerves of both the right and left facet joints at the same level, you should report this as bilateral. For instance, if a physician performed RF ablation to the right and left C5 medial branch and also the right and left C6 medial branch, this would be reported as a single level (C5-C6) bilaterally.

Many payers request that you append modifier 50 (Bilateral procedure) to the CPT® code to designate a bilateral procedure. Verify whether this is the case for your payer in question, however.

Example: Some payers do not accept modifier 50 in this situation. "When you use the 50 modifier for a bilateral procedure for one of our payers, the payer will deny the claim for invalid modifier use," says Linda Katicich, facility manager for Tallahassee Neurological Clinic's division of pain management. "For some reason, they want each injection on a separate line item."