Wiki 64625

mr628

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Mark, IL
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We are being denied payment from Medicare for all 64625. Is anyone else having this problem? Is there anything different we can do? Date of service is 5/26/20


Left lower back pain

Injection
Sacroiliac Joint: Sacroiliac Joint RF

Prior to Procedure
Prior to Procedure: Time out completed before, Informed consent obtained, Risks explained, Benefits explained

Patient Position
Patient Position: prone

Imaging Modality Used
Imaging Modality Used: Fluoroscopy
Fluroscopy View Used: AP view, lateral view, 10 degree cephalad view
Time exposed to radiology:
1 minute and 8 seconds

Level
Level: Left

Procedure
Level Place: Left, SA(Sacral Ala), S2, S1, Lateral Branches
Number of Injection Sites: 5

Needle Gauge, Length, Type
Needle Gauge: 20 Gauge
Needle Length: 100mm
Needle Used: Stryker Venom Needle

Testing
Motor Testing: Left, S2, S1, SA, 3.0 Volts
Extremity motor stimulation: No

Medications
Depomedrol Dose: 80 mg
Bupivacaine 0.25%ml each Level: 2 ml
Bupivicaine 0.25%ml total dose: 10 ml

Lesioning
RF Lesion at each level: 80 degrees Celsius for 90 seconds, radiofrequency ablation

CSF Present
CSF Present: Negative

Heme Present
Heme Present: No

Parasthesia
Paresthesia Present: No

Post-Procedure
Procedure done under: Local
Patient Physical Location: Pain Clinic
Complication: no complications
 
You should try M53.3 for sacral pain. We use that can dont have any issue getting paid. Its not really Lumbar pain here. With M54.5, Medicare will be looking for the Lumbar RFA codes.
 
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