Wiki PLEASE HELP with Radiofrequency denials

[Lamunoz2018]

I work for a pain clinic and my doctors perform radiofrequncy injections. I believe we are billing them correctly 64635x1 and 64636x2 when three nerves are injected. However we have ran into issues with an insurance that is denying the additional unit and stating we can only do two (64635x1 and 64636x1). I am wondering if anyone has fought an insurance on this issue or has any information/articles I can use to show this insurance that it is appropriate to do three nerves. Our local LCD limitations are:

Limitations of Coverage:
A maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per rolling 12 month year in the cervical/thoracic spine and five (5) in the lumbar spine.
For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels.
Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intraarticular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented.
Non-thermal RF modalities for facet joint denervation including chemical, low grade thermal energy (<80 degrees Celsius), as well as pulsed RF are not covered.
Intraarticular and/or extraarticular facet joint prolotherapy is not covered.

 

[dwaldman]

The LCDt has to be followed so only two levels bilateral can be performed based on the policy you are reviewing. You can see in the comments sections potentially where 3 levels might of been threshold that some providers might feel they should of based this on, but since they state only two levels bilateral then that it something that has to be take into consideration as part of their coverage policy and I don't believe they will make any exceptions.

Below is from AMA CPT Assistant----- three nerves for example L2, L3, L4 would innervate L3-4, L4-5 facet joints. The codes 64633-64636 are reported per facet joint level and you would want to make sure you are counting per facet joint. I mention this because you describing reporting per nerves versus facet joint levels.



AMA CPT Assistant February 2015

Destruction by neurolytic agent of the facet nerves is now reported based on the number of facet joints that are treated using the codes from the 64633-64636 series.

Although two nerves innervate each facet joint, the number of nerves treated does not affect code selection. This is reflected in the term "nerve(s)" which is included in the code descriptors. Therefore, only one unit of service may be reported for each joint regardless of the number of nerves treated. To clarify, the typical patient has two nerves treated for each facet joint. These nerves are at two different vertebral levels; however, the code is reported once per joint treated no matter how many nerves are treated.

In keeping with other procedures involving the vertebra, the code structure is based on spinal region. Codes 64633 and 64634 specify the cervical and thoracic regions, while codes 64635 and 64636 specify the lumbar and sacral regions. Codes 64634 and 64636 are add-on codes. These codes are reported for each additional facet joint at a different vertebral level in the same spinal region. Because each additional level is reported using codes 64634 and 64636, modifier 51, Multiple procedures, is not appended to these codes. If the additional level(s) is treated bilaterally, modifier 50 may be reported. It is important to note that the procedure must be adequately documented in the medical record.

Example

A 65-year-old female with a flexion-extension injury from an automobile accident presents with constant low-back pain. The patient's history includes imaging studies with findings of minimal degenerative disc disease and no facet arthropathy. The patient had no relief with conservative treatments such as physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), or trigger point injections. Previous trials of lumbar medial branch blocks unilaterally of the L3-4 and L4-5 facet joints provided significant short-term relief from her low-back pain. She undergoes radiofrequency neurotomy of the two medial branch nerves innervating the symptomatic facet joint, as well as the medial branch nerves innervating an additional symptomatic facet joint.

This example is reported using codes: 64635 and 64636.

Although three nerves were treated, only one unit of service is reported for each code. Likewise, only one unit of service is reported even when multiple lesions along a single nerve are treated. Codes 64634 and 64636 are add-on codes; therefore, modifier 51, Multiple procedures, is not required.

To report these procedures appropriately, physicians must clearly document the following: vertebral region level(s) (eg, cervical, thoracic, lumbar, etc), the facet joints (eg, L3-4, L4-5) involved, and whether the procedure(s) is unilateral or bilateral. Although the number of nerves and/or lesions might be noted in the clinical note, these factors do not influence the code selection or the number of units reported.

In addition, the following procedures are included in the services described with code series 64633-64636:
•Fluoroscopy or CT Guidance
•Injection of any contrast, steroid or local anesthetic agent

 

[Lamunoz2018]

Correction, our doctors are doing the levels by facet levels and not by nerves. The LCD also states that it could be four levels unilaterally. So if a patient is having 3 facet levels done unilaterally during 1 session the insurance is denying this. I have seen recent topics on RF's and everything that I have read states that you can bill 64635x1 and 64636x2.

 

[dwaldman]

If they are denying the 3 levels unilaterally, I would review the diagnosis and I would review those patients to see if it has been six months since the last RF procedures. I would also review if they have had 2 diagnostic blocks with >= 80% relief. If all this has also been met, I would send in a formal appeal to try to get in writing what the issue is.

Only when dual MBBs provide ≥ 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may facet joint denervation with RF medial branch neurotomy be considered.

•Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced ≥ 50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months