Hi! I have a coding question on a Neurotherm Simplicity probe procedure that one of our doctors in our ASC performed.

The doctor stated the procedure was a right sacroiliac joint radiofrequency ablation with NeuroTherm Simplicity probe.

Procedure: The patient was taken to the operating room and positioned prone on the fluoroscopy table. Pressure points were padded, intravenous access was confirmed, and monitors were applied. Monitored anesthesia care and sedation was induced.

Under AP fluoroscopy, the lumbosacral spine was surveyed. The area was prepped sterilely with Betadine. Using a 22-gauge, 7-inch needle, a course of local anesthetic was made initially on the skin of the buttock through the gluteal muscle, and down along the bony course of the sacrum on a track, which took it lateral to the neural foramen, and medial to the sacroiliac joint itself. After cutaneous anesthesia, the puncture site was made with an 18-gauge needle, and a NeuroTherm Simplicity probe was put into the right buttock, and guided with a combination of AP and lateral fluoroscopy down to the sacrum, and advanced on a course which took it lateral to the neural foramen line and medial to the joint.

The curves in the sacrum could not be followed with the probe, so technique was changed to Simplicity II pattern. The protocol was run. Then, the probe withdrawn and inserted in a more craniad insertion site, and the upper portion of the sacrum was approximated by the probe with a second insertion. So, a second Simplicity II protocol was performed. Because of the patient's instrumented fusion, the sacral notch was obscured by instrumentation and fusion mass, so a L5 radiofrequency ablation was not done.

The doctor never stated which levels of the sacrum that he injected. Would we only be allowed to code one procedure code (64640-RT) because the levels were never verified? It doesn’t appear that anything was injected on the first attempt either. I don’t believe we would be able to bill for the first attempt either?

Thanks for your help!