Mbb

BeckyGK

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I would like to know on the MBB done with fluoroscopy, how you would code this scenerio for 2012. I had some previous info from MHammer, but it is old. Any articles referenced would be great also.

RT & LT L4,5 facet median nerve branch block and L5 Dorsal Ramus nerve block ....
a 22 G 3.5 inch spinal needle with tip slightly bent was inserted under AP fluoro guidance to lay at the junction of the vertebral body and transverse process. Needle was advanced & adjusted to lay on the desired position under oblique view using fluoro guidance. One cc of bupivacaine 0.75% per level was injected and total of Triamcinolone 40 mg was divided equally on all levels Total needles used is 6 needles.
 

aaron.lucas

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I would say 64493-50 & 64494-50 for the MBB (they are bilateral right?), and then perhaps 64450 for the dorsal ramus, cause I cant find anything else that matches that, and 64450 says "other peripheral nerve or branch"? although not sure if that's correct either because I dont know that the dorsal ramus nerve is peripheral or a branch. But I'm confident about the MBB, and dont forget since 2010, no fluoro with the MBB. hope this helps! :)
 

BeckyGK

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Sorry I should have put this in the information from MHammer:

For a period of time, some providers considered the L5-S1 facet joint to have innervation from 3 nerve branches rather than the standard two...
L4 medial branch that is injected at the L5 vertebral body
L5 dorsal ramus that is injected at the sacral ala
AND a communicating branch from the S1 spinal nerve.

Newer anatomic research has found that there isn't a communicating branch as once thought and many pain mangement providers now only inject the L4 medial branch and the L5 dorsal ramus to block the L5-S1 facet joint.

With that said, the provider is still only blocking 1 facet joint level - L5-S1 and as such would be reported as 64493

Also to say that I am looking for where she may have gotten the information from a book showing this or where. I am telling Dr one code 64493 or 64493/50 if bilateral, but I am looking for more corroboration to show my doctor possibly newer for 2012 info would be great too.

I had also seen this:

06-07-2011, 10:28 AM
theso13
New Join Date: Apr 2007
Posts: 7


MNBB and Dorsal ramus injections
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Our doctor wants to bill for L4-5 median nerve branch block as well as for a L5 dorsal ramus procedure. Can both 64493 and 64494 be billed with these levels?

#2
06-08-2011, 07:55 PM
dwaldman
True Blue Join Date: Apr 2007
Posts: 611



________________________________________
Below CPT Assistant references would support two facet levels in the lumbar region represented by 64493 as described by the L3,L4 medial branches that innervate the L4-L5 facet joint and 64494 for the L4 medial branch and L5 dorsal ramus innervating the L5-S1 facet joint.

August 2010 CPT ASSISTANT

The L3, L4, and L5 medial branch nerves innervate the L4-L5 and L5-S1 facet joints. Therefore, code 64493,Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level,is reported for the first joint injected or blocked (L4-L5). Code 64493 is reported for a single or initial level treated. Add-on code 64494,Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure),is reported for the second joint or level injected or blocked (L5-S1).

Additionally from September 2004 CPT ASSISTANT

"It should be further emphasized that codes 64475, 64476, 64479, and 64480 refer to the injection of a facet joint either by injection into the joint with one needle puncture or by anesthetizing the two medial branch nerves that supply each joint (two needle punctures). For example, a left-sided L4-L5 intra-articular injection performed with a single needle puncture would be coded as 64475. Injection of the L3 and L4 medial branch nerves supplying the L4-L5 facet joint would also be coded as 64475, even though two separate injections are performed to effect the same result."


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aaron.lucas

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OH, ok, the way you listed it before made it look like two separate levels, but now it looks like one joint bilateral, plus the dorsal ramus, so now I'm thinking 64493-50, and then 64494 with no modifier? From what the CPT assistant info says that seems to be how it should be coded. as far as I know there weren't really any changes to the facet injection codes, so you should be safe using the 2010 assistant.
 

BeckyGK

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Yeah I know confusing. I am going to a meeting that Marvel Hammer is going to speak at on this subject maybe she will have some newer references. Thank you
 
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