With multiple ways to denervate the sensory nerve/nerve branches, pain management coders may argue about which 64xxx code is right. You’ve got to dig into the chart note to identify the method used. See if you’re up to the challenge with this Supercoder Forum Insight.
Question: A provider is doing RFA’s of the left L4, L5, S1, S2, S3 and SA. He is billing 64622 x 1 and 64623 x 4. The other pain provider states this is incorrect and that he should be billing 64640 for S1, S2, S3 and SA. Which coding is correct?
Answer: This is a complex coding issue because there are several different methods to denervate the sensory nerve/nerve branches that provide innervations from the SI joint. Because of this, the coding will depend somewhat on the method used.
However, I can say that reporting 64622 and 64623 x 4 is incorrect. The “paravertebral facet joint nerves” that provide innervations to the facet joints in the cervical, thoracic, and lumbar regions are the medial branches off the dorsal ramus. In the sacrum, there are indeed medial branches, but – as their name indicates – the path for these nerve branches is to the midline to provide innervations to the multifidus muscles and not laterally to the SI joint. So, following the published CPT Instructions for Use of the CPT Codebook – “Do not select a CPT code that merely approximates the service provided”, even though they are similar, procedures performed on the lateral branches of the sacral nerves should not be reported as paravertebral facet joint nerve procedures (i.e., paravertebral facet joint injections or destructions).
A few of the more common techniques are:
- Separate destruction of each nerve/nerve branch. According to CPT Assistant (Dec. 2009), you would code 64622 for the L5 dorsal ramus and 64640 x 3 for the individual lateral S1, S2, and S3 branches. If the provider also does an RF ablation of the L4 medial branch, add 64623 x 1 for destruction of that facet joint nerve.
- Destruction of the sacral nerves via placement of a single RF probe midway between the lateral border of the sacral foraminal openings and the medial border of the SI joint. The single RF probe has multiple active electrodes. Code with 64999 (per CPT Assistant, Dec. 2009) because the technique and physician work are much different from the multiple separate destructions.
- Destruction of the sacral nerves via a “strip lesion” along the posterior border of the SI joint or insertion of the RF probe(s) into the posterior SI joint. In private response to a pain management practice’s paid question, the CPT Knowledgebase responded that this type of technique would also be reported with 64999.
So, as is often the case, the coding answer will be “it depends!” Once you know which method your doctor used, you can decide on the correct code. Check out CPT Assistant Q/A (Dec. 2009) for more details on coding for the different methods. And you could always send the question to the CPT Knowledgebase and get a written answer for your physician.
From: Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO
