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RFA of the Third Occipital nerve

  1. #11
    Default RFA Third Occiptal Nerve and/or C2-C3 ablation - understanding op reports
    Exam Training Packages
    I am trying to follow along here in an effort to better understand my own ASC coding for pain management injections... but I think there is too wide of a gap between my understanding of named procedures and actual procedural descriptions. I am a CPC-A and have only been coding less than one year. I have two op reports for the same patient/dx with what I believe to be the same procedures with only different laterality. I had thought to code the first report with ablation of TON, C3-C4, & C4-C5 with 64633-LT, 64640-LT & 64634-LT and the second report with like codes of 64633-RT, 64640-RT & 64634-RT. But now I am concerned that I am missing ablation of C2-C3 in addition to the TON. Since reading on the forums here, I understand that TON is likely inclusive in C2-C3 ablation, so maybe I should be coding 64633 and 64634x2? Truthfully, I can not tell from the details in these reports if this is just a TON ablation or TON with C2-C3 ablation.

    I am hoping a knowledgeable pain coder will review these reports and explain what I should be looking for to decipher these procedures and/or direct me to some online resources that I can use to teach this to myself - I work independently from home as a contractor and I need to get this down. I find good information here and online, even though I have to translate the advice through the timing of the CPT changes rolled out - I think that some information is too old to trust despite my familiarity with the updates.

    Here are the two op reports that I am struggling with:
    POSTOPERATIVE DIAGNOSIS: Cervical spondylosis with cervical facet arthropathy.
    PROCEDURES PERFORMED:
    1. Radiofrequency ablation of the 3rd occipital nerve on the left side.
    2. Additional levels, C4 and C5 medial branch radiofrequency ablation on the left side.
    3. Fluoroscopy for precise needle placement.

    INDICATIONS: The patient is a pleasant 57-year-old female with complex medical history who has undergone a series of 2 successful diagnostic nerve blocks of the 3rd occipital nerve as well as C4-C5 medial branches bilaterally. She underwent right-sided radiofrequency ablation of the same nerves previously on August 31, 2015, with some relief in her pain. She presents today to complete procedure and have the left side done.

    1 - PROCEDURE IN DETAIL: An informed consent was obtained. The patient was taken to procedure room, was positively identified by the staff and the attending physician. The patient was positioned prone on the procedure bed. Vital signs were monitored as above and remained stable throughout the procedure. Monitored anesthesia care was utilized for the procedure. The skin was prepped and draped in a standard sterile fashion with chlorhexidine, followed by Betadine. A surgical pause time-out was performed and was agreed upon by the members of the team. A fluoroscopic view of the cervical spine was obtained and area of interest was identified. The skin was anesthetized using 1% lidocaine and-gauge 1.5-inch needle.

    After that, a 20-gauge 10cm RF cannula with 10mm active tip was advanced slightly above the C2-C3 facet joint on the inferior portion of the C2 lateral mass on the right side. The needle's position was verified in the lateral view in order to assure the tip of the needle was in the appropriate position in the inferior portion of lateral mass. Additional RF cannulae were placed in the C4 and C5 lateral masses in the mid portion of each articular pillar on the left side. Full contact with the osseous structures was established. Each level was stimulated for sensory fibers at 50 hertz and the patient's pain was reproduced between 0.3 and 1 V. The motor fiber recruitment was ruled out by stimulation at 2 hertz in the range between 0.5 and 2.5 V, only localized twitching of the paraspinal muscles was elicited. The patient was specifically without any radicular complaints. Prior to lesioning, each nerve was then anesthetized with 0.5 m of 1% lidocaine. This was not carried out at third occipital nerve region as further cannulae were subsequently placed at the midpoint of C2-C3 facet joint as well as superior portion of the C3 lateral mass corresponding to the inferior portion of the C2-C3 facet joint to anesthetize other known locations of the 3rd occipital nerve. Again, local was not administered prior to lesioning at the 3rd occipital nerve area in an effort to maintain the ability to perform sensory motor stimulation. Before removing the radiofrequency cannulae, 1 lesion was performed at each site at 70 degrees for 105 seconds. The radiofrequency cannulae restyletted and removed at the end of the procedure. All needles were withdrawn. Patient tolerated the procedure well. The patient was transferred in stable condition to the recovery room.

    2 - PROCEDURE IN DETAIL: An informed consent was obtained. The patient was taken to the procedure room and was positively identified by the staff and the attending physician. The patient was positioned prone on the procedure bed. The vital signs were monitored as above and remained stable throughout the procedure. Monitored anesthesia care was utilized for the procedure. The skin was prepped and draped in standard sterile fashion with chlorhexidine. A surgical pause time-out was performed and was agreed upon by the members of the team. A fluoroscopic view of the cervical spine was obtained, and the area of interest was identified. The skin was anesthetized using 1% lidocaine and 25-gauge 1-1/2-inch needle.

    After that, a 20-gauge 10-cm RF cannula with 10-mm active tip was advanced slightly above the C2-C3 facet joint on the inferior portion of the C2 lateral mass on the right side. The needle's position was verified in the lateral view in order to assure that the tip of the needle was in the appropriate position in the inferior portion of the lateral mass. Additional RF cannulae were placed at the C4 and C5 lateral masses in the mid-portion of each articular pillar on the right side. Full contact with osseous structures was established. Each level was stimulated for sensory fibers at 50 Hz, and the patient’s pain was reproduced at approximately 0.8 V. The motor fiber recruitment was ruled out by stimulation at 2 Hz in the range between 0.5 and 2.5 V. Only localized twitching of the paraspinal muscles was elicited. The patient specifically denied any radicular complaints. Prior to lesioning, each nerve was then anesthetized with 0.5 ml of 1% lidocaine. This was not carried out at the third occipital nerve region, as further cannulae were then placed at the midpoint of the C2-C3 facet joint as well as the superior portion of the C3 lateral mass corresponding to the inferior portion of the C2-C3 facet joint. Again, local was not administered prior to lesioning at the third occipital nerve area in an effort to maintain the ability to perform motor stimulation. Before removing the radiofrequency cannulae, 1 lesion was performed at each area at 70 degrees for 105 seconds. The radiofrequency cannulae were restyletted and removed at the end of the procedure. All needles were withdrawn. Patient tolerated the procedure well. The patient was transferred in stable condition to recovery room. Due to extensive needle manipulation and concern for hematoma format ion, the decision was made to defer the left portion of this procedure to another date.

    Thanks in advance!

  2. #12
    Location
    Denver Colorado
    Posts
    279
    Default Ton
    The third occipital nerve (TON) provides the primary innervation to the C2-C3 facet joint. If thermal RF ablation is performed at the C2-C3 joint denervating the TON, it would be "counted" as one facet joint level. The documentation you included did not include procedure description of the C4 & C5 medial branch RF ablation, only the TON procedure twice. IF the documentation does include description of the C4 & C5 medial branch RF ablation, then this would be a second facet joint level.

    IF all three nerves (TON, C4 and C5 medial branches) were thermally radiofrequency ablated, then the coding would be 64633-LT x 1 and 64634-LT x 1

    IF this procedure was performed in 2016, there is an issue in that the temperature documented was only 70 degrees Celsius and 2016 CPT includes a new parenthetical note specifically for 64633-64636 codes: "Do not report 64633, 64634, 64635, 64636 for non-thermal facet joint denervation including chemical, low-grade thermal energy (< 80 degrees Celsius), or any form of pulsed radiofrequency. To appropriately report any of these modalities, use 64999" SO if performed in 2016, this would be 64999 x 1.

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