Wiki Can I bill for medications in addition to RFA?

[juli]

Hi,

I am attempting to code for an RFA and hope someone will be willing to read this op note and offer guidance:


Radiofrequency Ablation (RFA) of Lumbar Facet Medial Branch Nerves

Procedure Title(s):
1. RFA of Lumbar medial branch nerves on the LEFT and RIGHT side
- performed at the levels of L4,5,Ala levels
2. Intraoperative fluoroscopy

Pre-operative Diagnosis: Lumbar facet arthropathy

Post-operative Diagnosis: Lumbar facet arthropathy

Attending Surgeon: XXXXXXXX, MD

Anesthesia: Local Anesthesia

Name: XXXXXXXXX

DATE: 1/12/2015

INDICATIONS/DIAGNOSIS: Patient is here for today's planned radiofrequency procedure with complaints of low back pain. The patient denies any bowel/bladder dysfunction.

RELEVANT LABS:
PLT'S AUTO 246 07/05/2012
INR 0.97 11/29/2010

Indications: Patient is a 62 year old male with a diagnosis of lumbar facet arthropathy. The patient?s history and physical exam were reviewed. The risks, benefits and alternatives to the procedure were discussed, and all questions were answered to the patient?s satisfaction. The patient agreed to proceed, and written informed consent was obtained.

Informed Consent: The risks, benefits and alternatives to the procedure were discussed, and all questions were answered to the patient?s satisfaction the risks of the procedure including damage to the skin, worsening pain, weakness in the lower extremities, permanent damage to the nerve or spinal cord were presented and discussed with the patient

Procedure in Detail: The patient was brought into the procedure room and placed in the prone position on the fluoroscopy table. The area of the lumbar spine and upper buttocks were prepped with betadine times three and draped in a sterile manner. Attention was then first turned toward performing the RF at the lumbar medial branch of L4, An oblique fluoroscopic image was used to identify the target junction point where the SAP and the TP of the vertebral body fuse. The skin and subcutaneous tissues with 5cc of 1% lidocaine. A 20-gauge, 100 mm radiofrequency probe was advanced toward the target point under intermittent fluoroscopic guidance. Once bone was contacted, negative aspiration was confirmed. Sensory stimulation was performed at 50 Hz and 0.4 volts, generating a pressure sensation. Motor stimulation at 2 Hz and 1.2 volts was negative for lower extremity movement but associated paraspinal twitch was prsent. 1ml of 1% lidocaine was injection prior to lesioning, which was performed for 90 seconds at 90 degrees centigrade. Please see MA note for impedances. Once the lesion was complete, 2ml of a solution consisting of 4ml of 0.5% bupivacaine and 1ml triamcinolone (40mg/mL) was injected through each probe. The probes were removed with a 1% lidocaine flush.

Identicle procedures where performed at the other lumbar medial branch levels

I have a couple of questions, first, is this note complete enough to code at all? If it is, I come up with codes 64635-50 and 64636-50. Secondly, can I pick up the J3301 for the Kenalog?

Any/all assistance will be much appreciated !

 

[dwaldman]

The procedure heading states bilateral L4, L5, Sacral Ala.

The narrative states L4 medial branch and then the additional levels were performed in a similar manner.

It appears you have 2 medial branches L4, L5 that innervate the L5-S1 facet joint that was treated bilaterally.

Since radiofrequency ablation procedures of the facet joint nerves are reported per facet joint level, it appears that only one level is addressed.

I would code two levels if L3, L4, L5 medial branches were listed as contributing to the L4-5, L5-S1.

I would code three levels if L2, L3, L4, L5 medial branches were listed as being treated for the levels of L3-4, L4-5, L5-S1.

I believe the note is complete to bill one level L4, L5 for L5-S1 facet level with the 50 modifier.

You could bill the drug administered separately but it might be packaged per the setting the procedure was performed at.

 

[dwaldman]

Additionally I would not include lab values or patient's age, or date of service in the note for coding review.

 

[juli]

Thank you for your assistance! I will try to contact the provider, in order to get more clarification. I'm new to posting requests for assistance, I was not sure how much to include. I will be sure to submit only information regarding the procedure in the future.

 

[dwaldman]

Below is from AMA CPT Changes 2012, you indicated you would contact the physician. The reason I am providing the below information, there can be instances were physicians were not educated on the change in 2012 that radiofrequency ablation procedures are per facet joint not per medial branch that are ablated. As seen below, they state two nerves innervate each facet joint. The note that was provided specifically states L4 medial branch was treated with radiofrequency ablation then at L5/Sacral Ala. This would be the two nerves (eg, L4, L5) that is innervate the facet joint you are reporting for L5-S1. You want be prepared to remind the physician that it is per facet level since 2012 and these guidelines are in AMA CPT Changes 2012. Additionally, if the physician states he blocked the S1 branch contributing to L5-S1. You are still only reporting per facet level and L4, L5, S1 would be one level.

AMA CPT Changes 2012

The paravertebral facet joint nerve codes 64622, 64623, 64626, and 64627 have been deleted. Four new codes have been established to more accurately reflect the work and anatomical site involved in these procedures. Prior to 2012, the unit of service used to report these procedures was a single nerve at a single vertebral level. However, two nerves innervate each facet joint, and there are two facet joints at each vertebral level. One or two facet joints at the same level potentially could be treated. As such, the vertebral level is of less significance than the number of facet joints treated, so using vertebral level as the unit of service did not adequately reflect the work performed. To address this issue, the unit of service is a single facet joint in new codes 64633, 64634, 64635, and 64636, rather than a vertebral level. If both facet joints at the same vertebral level are treated, then the parent code (64633 or 64635) should be reported with modifier 50 appended. It is important to note that the number of nerves injected for a single facet joint does not affect code selection. Therefore, the new codes indicate "nerve(s)" in the descriptors.