Wiki Help with paravertebral jt injections 64635

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Hi ,New to Ortho coding, Can you please help with codes.?
"The right lumbar area was prepped with betadine times three and draped in the usual sterile fashion. The L4/5 vertebral body was identified with oblique radiographic view. The skin over the right L4/5 anterior ramus was infiltrated with 0.5% Lidocaine for local anesthesia. A 22-gauge RFL needle 5-inch needle was inserted adjacent to the right L4/5 ventral ramus under radiographic guidance. Both AP and lateral views were obtained. Following placement of the needle sensory stimulation at 50 Hz and motor stimulation at 2 Hz was carried out. After confirmation of needle placement by the patient reporting reproduction of pain on sensation in the area of symptoms and denying extremity motor sensations, RFL was carried out after local anesthesia with 1cc of 2% lidocaine. The settings were 80 degrees centigrade, and 90 seconds. The identical procedure was performed on right L5/S1 (sacral ala) ventral ramus and on the opposite side for a total of 6 RFL needles being used."

Provider billed 64635-50, and 64635-50
Cpt says no 50 mod for 64636, instead report 64636 twice if done bilaterally.
Not sure if L4/5 was done bilaterally. But for L5/S1 it does mention opposite side.
Should this be coded as 64635 and 64636*2 instead?

Thanks
 
Hello!

I work for a pain and spine specialist and we are constantly billing out MBBs with RFAs.

I read this as L4-5 64635-RT and L5-S1 64636-50.

I do not see the documentation that the L4-5 was done bilaterally - although AMA says not to use modifier 50, Medicare (at least in our state (ID)) still wants the 50 modifier and most payers follow their guidelines. If the payer you are coding for does not want the 50, I would code it as 64635-RT, 64636-RT, LT.

If you are using AMA guidelines, when you have a procedure that would normally use a 50 modifier, AMA wants RT and LT on the line item. They do not want it billed as two units or with two lines, one with RT and one with LT. It will go on one line with the right and left modifiers.

Hope this helps!
 
bdcoyne8 said:
Hello!

I work for a pain and spine specialist and we are constantly billing out MBBs with RFAs.

I read this as L4-5 64635-RT and L5-S1 64636-50.

I do not see the documentation that the L4-5 was done bilaterally - although AMA says not to use modifier 50, Medicare (at least in our state (ID)) still wants the 50 modifier and most payers follow their guidelines. If the payer you are coding for does not want the 50, I would code it as 64635-RT, 64636-RT, LT.

If you are using AMA guidelines, when you have a procedure that would normally use a 50 modifier, AMA wants RT and LT on the line item. They do not want it billed as two units or with two lines, one with RT and one with LT. It will go on one line with the right and left modifiers.

Hope this helps!
Click to expand...
Thanks Brittany.
Trying to understand the documentation, what does he mean by a 'total of 6 RFL needles used" . I am trying to break this down, Is it
2 needle at L4/L5 joint right side only,
2 needles at L5/S1 right side and
2 needles at L5/S1 on left side?
Is this how generally RFL done. 2 needles for the two nerves.?
Thanks again
 
His documentation is confusing. I would advise education. However, when understanding how RFAs are done, the providers typically inject the level above the levels they are intending to treat as well. This ensures that they are giving the maximum benefit to the patient. Here is an example of our documentation so you can see the difference.

The right and then the left, L3-4, L4-5, L5-S1, level(s) were identified and a skin wheal was made at the targeted injection site(s) using 1 mL of 1% lidocaine with a 27-gauge, 1.25 inch needle. At the juncture of the superior articulating process and transverse process, expected position of the, L2 medial branch nerves, L3 medial branch nerves, L4 medial branch nerves, L5 medial branch nerves, as confirmed by intermittent AP, oblique and later Fluoroscopic views. A 18-gauge, 15 cm curved radiofrequency cannulae with a 10 mm active tip was advanced towards each target zone in a cephalocaudad direction of approximately 20 degrees relative to the end plate of the vertebral body at each level, and approximately 15 degrees lateral to AP. Final needle positioning was performed in the lateral fluoroscopic view, so that the needle tip overlaid the middle of the superior articular process, but did not enter the neural foramen. Once all needle(s) were considered to be in a satisfactory fluoroscopic position, and in contact with bone, sensory and motor stimulation was performed. Sensory stimulation was performed at 50 Hz, and was considered positive if pain was produced in a concordant fashion at a voltage less than 0.5 mV. Motor stimulation was performed with a goal to see multifidus twitching in the absence of upper extremity motor twitching at the voltage greater than 3 times the magnitude of the sensory threshold. This was performed at all level(s). After satisfactory sensory and motor stimulation was complete, a solution containing, lidocaine 1% 2 mL, was placed through the needle(s) at each level. Radiofrequency cannulas were then placed in the needle(s), and lesioning was then performed at 90 degrees Celsius for 60 seconds at each level. The needles were rotated 180 degrees and lesioning was then performed again at 90 degrees Celsius for 60 seconds at each level. The needle(s) were removed. Hemostasis obtained. Sterile bandage(s) were applied. The patient tolerated the procedure well. The patient was transferred to the recovery room in stable condition.

When you look at this, the providers targeted areas are L3-4, L4-5 and L5-S1. 3 levels. But when you read the next line down, he mentions the L2, L3, L4 and L5 nerves. When they inject this medication, the meds travel down so that's why they start one level up for their targeting levels. He starts at L2 to target L3, L3 to target L4, L4 to target L5 and L5 to target S1.

This is where the needles come in. Because they start one level up, there will be an extra 1 or 2 needles, depending on laterality, for these procedures. Since he is doing these bilaterally, there would be 8 needles although he is only targeting 3 levels. That is because he started 1 level higher (L2). 2 needles for L2, 2 for L3, 2 for L4 and 2 for L5 = total of 8.

That is why I am confused by his documentation. Based solely on what I am reading where the is no mention of the higher level, I only see 3 needles. One for the L4-5 RT and 2 for L5-S1 bilaterally. I would query where the other 3 are coming from. If it is they way I think it is, where he is actually doing the level above so the meds come down, he will need to document that he starts are L3 for the L4 and L4-5 for the L5-S1. That would get you 5 needles. L3(RT)=1. L4(50)=2 L5(50)=2.

You should be also to see the total number of needles on your image. It's pretty clear on ours the number of needles and injections performed.

These are very weird to learn when you are first starting! It gets better though!!
 
Ok. I am beginning to understand. I am surely in a better place than I was couple of hrs ago LOL.
So in your example , if it is Medicare we would code 64635-50, 64635*2, 50. Correct?
Unfortunately I cannot see the images in Epic. That would be nice to visually see them.
Thanks so much for the detailed explanation.
 
If it is Medicare, you would bill the first line 64635-RT (I don't see that it was bilateral, it if is, then yes, add the 50), and 64636-50.

Medicare does not want additional units. Only 1 unit per line.

It should look like this on the claim form:
64635-RT
64636-50

If done bilaterally:
64635-50
64636-50

:)

This is also how we code this in our clinic in Idaho based on our LCDs and Medicare MAC guidelines. It could be different where you are located. Be sure to review those there!
 
Sorry,I think I am confused by the joints. I am using your example for learning because your documentation is better than the one I have. If I code yours correctly, I will be able to apply that to other documentation from my providers.

In your example , L3-4, L4-5, L5-S1 , there are 3 joints . All three were done bilaterally.,
So shouldn't we bill
64635-50 for the L3/4 joint and
64636 *2, 50 for the L4/5 and L5/S1 joints along with 50 mod to account for the 3 joints?
 
Correct, if your provider is targeting 3 joints. I don't see where he is targeting. He is targeting 2 on his documentation. So it would only be the 2 levels you code for.

In mine, it would look like this:
64635-50
64636-50
64636-50

We are instructed here in Idaho not to bill it as 64636*2-50
We have to break it out into each line separately.
MA might be different so if they are wanting units and not lines, then you are correct.
64635-50
64636*2-50

Yours would only be the 2 levels based on your providers documentation:
64635-RT
64636-50

If your provider did bilateral on the first level, they need to make that clear because it is not clear in the documentation that both sides were done.
 
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