Anesthesia Coding Alert

Pay attention to what can and cannot be billed separately with electrical stimulation, RFA.

Physicians can choose from several different techniques — injections, blocks, radiofrequency rhizotomy, electrical stimulation, among others — to combat severe pain. As such, patients that require interventional pain management (PM) can present a few coding hurdles.

With so many treatment modalities for your PM physician to choose from, you must be familiar with the basics of coding each type of interventional PM technique to ensure maximum accuracy and claim success.

This article focuses on the info you’ll need to strengthen your electrical stimulation and radiofrequency rhizotomy coding skills. For information on injections and blocks, see “Find These Facts for Flawless Injection Reporting” in Anesthesia Coding Alert, volume 25, no. 6.

Zap Pain Away Via Electrical Stimulation

An interventional PM technique many specialists employ is electrical stimulation, which uses targeted electricity (via neurostimulator electrodes) to treat the patient’s pain. Patients who undergo this procedure might require several different services during their PM treatments, including electrode insertion and removal and neurostimulator removal, revision, and replacement.

According to Marilyn Torres, COC, CPC, CANPC, coding/ billing supervisor at Meridian Medical Management in Belleville, New Jersey, and Amy C. Pritchett, BSHA, AAPC Fellow, CCS, CRC, CPC, CPC-I, CPMA, CPCO, CDEI, CDEO, CDEC, CANPC, CEDC, CASCC, CMPM, Approved ICD-10-CM/PCS Trainer, senior consultant at Pinnacle Healthcare Consulting in Mobile, Alabama, they often use the following codes for their providers’ electrical stimulation interventional PM treatments:

Implantation

• 63650 (Percutaneous implantation of neurostimulator electrode array, epidural)
• 63655 (Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural)
• 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling)

Remember to also bill for the implantable neurotransmitter pulse generator using HCPCS Level II code L8679 (Implantable neurostimulator, pulse generator, any type).

Removal/Revision

• 63661 (Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed)
• 63662 (Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed)
• 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver)
• 63663 (Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed)
• 63664 (Revision including replacement, when performed, of spinal neurostimulator electrode plate/ paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed)

Note: This is not intended to be a complete or approved list of electrical stimulation treatments for interventional PM. Always choose the CPT® code that most closely represents the provider’s actions during the encounter — and append modifier 50 (Bilateral procedure) when they perform bilateral procedures.

Important: Be sure to also bill for each implanted neurostimulator electrode with L8680 (Implantable neurostimulator electrode, each).

Remember, RFA = Rhizotomy

One method of interventional PM your provider might use is radiofrequency rhizotomy, also called radiofrequency ablation (RFA), confirms Pritchett.

RFA “is one of the newest pain control techniques. In this nonsurgical procedure, radiofrequency waves are delivered to certain nerves, with the goal of interrupting pain signals to the brain. RFA typically targets pain from the facet joints, which can contribute to chronic pain in the neck or lower back, and the sacroiliac joints, which can contribute to chronic low back pain,” according to guidance from the University of California San Francisco (www.ucsfhealth.org/treatments/radiofrequency-ablation).

Note: Since RF lesioning causes nerve destruction, PM doctors resort to this technique only as an “end of the line” therapeutic modality when other measures have failed.

“Many payers require the patient have severe pain-limiting activities of daily living for at least three months despite documented conservative treatments such as structured exercise, formal physical therapy within the past six months, activity modification, weight loss, and/or drug therapy,” explains Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, retired owner of MJH Consulting in Denver.

“The conservative treatment requirements vary depending upon anatomic source of the chronic pain as well as the individual payers,” she adds. “It is best to check with the patient’s insurance coverage policies to make sure that all requirements are met and documented.”

PM physicians use radiofrequency rhizotomy to ablate pain pathways in numerous locations. Here are the RFA codes most used by Pritchett and Torres:

• 64620 (Destruction by neurolytic agent, intercostal nerve)
• 64624 (… genicular nerve branches including imaging guidance, when performed)
• 64625 (Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography))
• 64630 (Destruction by neurolytic agent; pudendal nerve)
• 64633 (… paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint)
• +64634 (… each additional facet joint (List separately in addition to code for primary procedure))
• 64635 (Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint)
• +64636 (… each additional facet joint (List separately in addition to code for primary procedure))
• 64640 (Destruction by neurolytic agent; other peripheral nerve or branch).

These RFA codes describe a unilateral procedure, so when your PM physician performs RFA bilaterally, append modifier 50 to the RFA code.

Note 1: This is not intended to be a complete or approved list of RFA treatments for interventional PM. Always choose the CPT® code that most closely represents the provider’s actions during the encounter.

Note 2: Some of the codes listed above do not appear sequentially in the CPT® code book. Before submitting the claim, check with the payer on these codes, as they might have their own guidelines for reporting these RFA codes. And above all, make sure you pay attention to which RFA code you are choosing in the CPT® code book; when codes are out of sequence, it can put coders out of sorts.

Keep in mind: Imaging guidance (fluoroscopy or computerized tomography (CT)) and any injection of contrast are inclusive components of 64633-64636, as they are required for the performance of paravertebral facet joint nerve destruction by neurolytic agent described by these codes. To report imaging techniques other than CT or fluoroscopy, use 64999 (Unlisted procedure, nervous system).