Radiofrequency S3,S4,S5

dyoungberg

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I'm needing to bill out the following operative note and was hoping someone out there could provide their thoughts on the way to code diagnosis and procedure.



DIAGNOSIS: INTRACTABLE LOW BACK PAIN SECONDARY TO LUMBAR FACET SYNDROME

PROCEDURE: RADIOFREQUENCY THERMOCOAGULATION TO THE DORSAL MEDIAN BRANCH OF S3,S4,S5 AT THE NEURAL FORAMEN OF S3,S4,S5 ON THE LEFT SIDE

DESCRIPTION OF PROCEDURE: We had a lengthy discussion with the patient of the risks and benefits of this procedure, including the possibility of infection, no pain relief, hematoma as well as the possibility for inadvertent puncture of a nerve root. We discussed neuritis in detail with the patient and that neuritis is likely to occur and generally will occur approximately five days following the procedure and will last approximately one to two weeks. The patient understands this will generally go away, but there are circumstances where this problem can persist, particularly in overly sensitive patients. The patient also understands that this will no help at all with problems other than lumbar facet syndrome. The patient understood that there were no guarantees made or implied as to the long term efficacy of this procedure.

After informed consent was obtained, the patient was brought to the fluoroscopy table and placed prone and carefully prepped and draped in the usual fashion. Alfenta was used for sedation. Then utilizing direct fluoroscopic guidance as well as AP, lateral, and double oblique imaging, we inserted thin walled 22 gauge Radionics needles with 10 mm active tips. The needles were placed in the groove of the sacral ala, and the needles were placed in approximately the 10 o'clock position of the neural foraminal outlets of S3,S4,S5on the left side. After each of the needles were placed and their position was confirmed in all three fluoroscopic views, we were able to obtain good sensory stimulation at 0.6 volts and 50 Hz. We then were able to ascertain that at 3 volts and 2 Hz there was no motor stimulation below the hip. After obtaining excellent electrical parameters in all locations, we then proceeded to anesthetize each level. Anesthesia was utilized with approximately 2 cc of 2% Xylocaine and 40 mg Kenalog through the needle at each location. We again confirmed and made fluoroscopic copies of the needle locations in AP and lateral views and we then proceeded to perform the rhizotomies.

Each rhizotomy was performed utilizing a 90 degree thermal lesion for 60 seconds. Throughout the rhizotomies we monitored impedance, wattage, voltage, and milliamperage. Electrical parameters were normal throughout all the procedures. Separate rhizotomies were performed. After completing the rhizotomies, the needles were removed, and an ice pack was placed over the operative site as well as a Band Aid.

The patient was taken to the recovery room where the patient was noted to be in good condition, tolerating the procedure well without any side effects or complications. There was good relief of the patient's pain. Discharge instructions were given, including instructions for the patient to notify the pain management unit and/or our office if there were any complications that were unexpected. These include numbness lasting greater than one hour following the procedure, alterations in the patient's ability to walk, ataxia, redness, warmth, any drainage from any of the operative sites at any time, prolonged fever, or significant increased back pain. After the patient was given these discharge instructions, the patient was discharged home in good condition.


I believe the correct CPT coding would be 64640 x 3. The ICD-9 codes would be 721.3 & 724.2 based on what the doctor provided. I'm hesitant to bill with these codes as Medicare LCD only lists 355.6,355.5, & 728.71 as valid dx codes for this procedure.

Any thoughts or experience on how I should bill this to Medicare.

Thanks and Happy Friday!

Debbie Youngberg
CPC-A
NW FL Surgery Center
 

dwaldman

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If the low back pain is documented as a result of the spondylosis, 724.2 would not be separately reported.

The other diagnoses that you stated were from an LCD sounded like although 64640 might be in the LCD it is not for the same type of procedure at the anatomical location being described.

I was thinking this procedure might be for treatment of nerves innervating Sacroilliac joint potentially with condtions such as SI joint dysfunction 739.4, SI joint pain 724.6, or sacroillitis 720.2 but not sure exactly.
 

hgolfos

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I have seen 64640 done at the S3-S5 levels, but it's usually to treat the SI joint as the nerves at those levels innervate the SI joint. I haven't seen this done to treat lumbar facet syndrome before, so I would double check with the provider to make sure there isn't some mistake in the dictation, unless you've already done that, in which case, I'm no help. :-(
 
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