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Rfa sij

  1. #1
    Default Rfa sij
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    This one has me a little stumped.. The doctor wants coded: 64635;64640 x3

    The op reports reads as follows:

    Procedure:
    Right RFA of sacroiliac joint, specifically the dorsal ramus of L5 and lateral branches of S1,S2 and S3.

    Patient was placed in the prone position. I identified the sacral ala and the superior articular process of S1. I prepped the area with chlorhexidine in the usual sterile fashion technique. I used lidocaine 2% for skin infiltration. I used a 22-gauge, 10-mm Active Tip needle. I advanced the needle until I had good position of the needle into the junction between the sacral ala and the superior articular process of S1. Then we identified the most median and superior part of the SI joint. I advanced the needle towards the most lower and inferior portion of the SI joint on the right side until I had good position of the needle into the above level in the AP and lateral views. The following technique was used to confirm placement at the median branch nerves.

    Sensory stimulation was applied to each level at 50Hz; paresthesias were noted below 0.6 microvolts. Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted. Following this, the need trocar was removed and a syringe containing 0.25% bupivicaine was attached. At each level, after syringe aspiration with no blood return, 1 mL of 0.25% bupivicaine was injected to anesthetize the median branch nerve and surrounding tissue. After completion of each nerve block, a lesion was created at that level with a temperature of 80 degrees Celsius for 90 seconds.

  2. #2
    Default
    If the L5 procedure is for innervation to the SI Joint, then I would go with 64640. I think it common that providers see L5 level as one innervating the Facet Joint at L5-S1 so they assume the same coding would apply but I don't believe it is correct because the code descriptor for CPT 64635 states innervating the facet joint and if that was not intention of the block and it was associated would similiar procedures for the SI joint, then I would use 64640 X4 for separate treatments/ablations


    AMA CPT Assistant June 2012
    Surgery: Nervous System

    Question: May code 64640 be reported for each individual peripheral neurolytic nerve destruction procedure performed at the L5, S1, S2, and S3 nerves?

    Answer: Yes. When performing individually separate nerve destruction, each peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code
    64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, for peripheral nerve root neurolytic blocks (destruction) of L5, S1, S2, and S3, code
    64640 should be reported four times. The coder should append modifier 59, Distinct Procedural Service, to the second and subsequent listings of code 64640 to separately
    identify these procedures.

  3. #3
    Default R sacroilliac RFA
    My providers note reads:
    PROCEDURE:
    Right Sacroilliac Radiofrequency Ablation (64635,64640x3,77002)
    -
    DIAGNOSIS:
    Preoperative Diagnosis:
    Chronic Low Back Pain
    Disorder of the Sacrum - Right
    Sacroiliac Dysfunction - Right
    Lumbar Spondylosis
    Postoperative Diagnosis: Same
    -
    INDICATION(s):
    This patient has failed and/or has contraindications to conservative therapies. This/these procedure(s) is/are medcially necessary to increase the patient''''s function and/or decrease the patient''s pain
    -
    CONSENT:
    The Risk, Benefits, and Alternatives of the procedure were discussed in detailed, and all presented questions were answered. The patient verbalized understanding and agreed to the procedure(s). A signed copy of the consent is available in the patient''''s chart.
    -
    LOCAL ANESTHETIC: Lidocaine 1% , 6 mLs
    INJECTATE: Bupivicaine 1 mL and Methylprednisolone (40mg/ml) 1 mL
    -
    PROCEDURE DETAILS:
    The patient was taken to the procedure room where a time out verification was completed, establishing the correct patient, procedure(s), any lateralization, and allergies. The patient''s vital signs were obtained and noted to be stable.
    -
    The patient was placed in the prone position. The operative area was preppred and draped in the usual sterile fashion. Using and A-P fluroscopic view, the corresponding ala, sacrum, and sacral foramen were visualized. Using a small guaged needle the areas overlying the target areas were anesthetized noted by a skin wheal with lidocaine 1%. Using, both, posterior/anterior and oblique views, a 10 cm 22 g radiofrequency needle with a 10 mm tip was inserted towards the course of the right L5 dorsal ramus. Thereafter, similar needles were placed just lateral to the S1, S2, and S3 foramen. Once the needle tips were in place, sensory stimulation was accomplished at each level with good response. Thereafter, motor stimulation, up to 2 volts was accomplished to confirm no motor involvement at each level. 1 mL of 1% lidocaine was then injected slowly at each level. After waiting 30-60 seconds, ablation was performed utilizing a radiofrequency generator at 80 degrees C for 90 seconds. One-half milliliter of an injectate was then administered. Thereafter the needles were removed.
    -
    The patient tolerated the procedure well.
    -
    After vital signs were taken and stable, the patient was taken to the recovery area for further observation. The neurological examination was essentially unchanged and no complications were noted.
    -
    FLUOROSCOPY:
    AP and oblique views were taken for guidance of needle insertion to the target points, as well as, confirming the needle tip position and depth.

    Per the thread on here as well as one I read on AHIMA's site indicates I can bill 64640 with a 59 modifier, the claim was billed:

    64635 -RT
    64640 -RT, 59
    64640 -RT, 59
    64640 -RT, 59
    77002

    One of my 64640 paid, the other two denied duplicate and the 77002 denied this procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the National Correct Coding Initiative or workers compensation state regulations/ fee schedule requirements.

    Do I need to appeal these denials for duplicates? I am not sure how else to get these paid and what would be my reasoning for the appeal to get the other two lines paid?

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