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RFA of the Third Occipital nerve

  1. #1
    Default RFA of the Third Occipital nerve
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    I have a provider that is doing a Radiofrequency Ablation right Cervical Facet Joint medical branch nerves; C2, C3, C4, C5, C6, and 3rd occipital nerve. He billed 64626-RT x 1 and 64627-RT, 64627-RT, 64627-RT, 64627-RT, 64627-RT. The insurance company is denying the 64627 stating this is an invalid procedure code for the 3rd occipital nerve. Any suggestions as to the correct CPT code for a RFA of the 3rd occipital nerve? Thanks as always for your help.

  2. #2

    The posterior division of the third cervical is intermediate in size between those of the second and fourth

    Its medial branch runs between the Semispinalis capitis and cervicis, and, piercing the Splenius and Trapezius, ends in the skin. While under the Trapezius it gives off a branch called the third occipital nerve, which pierces the Trapezius and ends in the skin of the lower part of the back of the head. It lies medial to the greater occipital and communicates with it."
    __________________________________________________ ____________
    I need to look further to find some information that would be useful to you. Some of the information from different sources I pulled up on the internet described it differently so I didn't know which one to copy and paste as the most reliable. You almost need a medical text book to support that this would represent what the descriptor in the code describes: "paravertebral facet joint nerve" If I see one of the physicians tommorow I can pose these questions--Is the third occipital nerve a "paravertebral facet joint nerve"? Or Could the 3rd occipital nerve be considered "other peripheral branch" as described in RFA code 64640?

  3. #3
    Thank You so mcuh. I will wait for your reply.

  4. #4
    I saw the physician who is familiar with this procedure and has recently performed one and coded it the way your physician did. He had been seeing patients at the outlying facilities all day so the conversation was brief because was late in the day.

    I asked the physician, "Is the third occipital nerve a paravertebral facet joint nerve?

    He said the third occipital nerve was a paravertebral nerve but he did not believe it would be correct to call it a paravertebral facet joint nerve.

    I asked the physician, "Could you refer to it as peripheral nerve?"
    He said do mean in like in the code 64640 (he is familiar with this code he does SI joint lateral branch RF) I said yes. He said you could possibly call it.

    He did seem to come to the conclusion that 64627 would not be the appropriate code due to the descriptor's wording and how he felt that it was not a facet joint nerve. Confirming whether you can compliantly report 64640 would have to come from the AMA's CPT Network. If I am able to pay for a question on this topic, I will create a new thread with part of my response, so I can follow up with you.

  5. #5
    I was wondering if the you were able to find out any additional information on this, dwaldman? Thanks for all your great help.

  6. #6
    Inquiry Question:
    I believe the below procedure should be coded as such: 64626 (C2), 64640 (TON), 64627 (C3), 64627 (C4) 77003

    Is it appropriate to report 64640 for destruction of third occipital nerve by radiofrequency ablation?

    Radiofrequency neuolysis cervical medial branches(facets) RIGHT X 4 Levels C2,TON, C3, C4 Fluoroscopy for needle guidance

    Above was part of my question Below is part of their response

    "64626 Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level

    64627 x2 Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)

    77003 x1 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction

    "It would not be appropriate to report code 64640 Destruction by neurolytic agent, paravertebral facet joint nerve; other peripheral nerve or branch. The third occipital nerve is the medial branch of C-3 and its location is similar anatomically with performing a paravertebral facet joint injection. However, the difference is that the location of the third occipital nerve may
    vary, so the physician may need to burn over a wider area to ensure capturing the third occipital nerve in the procedure."

  7. #7
    Thanks so much for all your help, but I am still confused. So which would be the correct CPT code to use since we can not use the 64640. Is the CPt code 64627 correct? It did not really sound like it. You're the best for taking so much time with me.

  8. Default
    Please clarify. Does this mean that billing for 4 levels is not correct? We are doing these now and I have been coding 64626 x1 64627 x3 77003 (LT or RT, depending on side). Is the TON part of one of the 64627 levels and not a completely separate level? I might not be understanding the final thread completely. This morning's been a little like that! Thanks!

  9. #9
    I submitted saying 4 level nerve destruction (RFA) stating one of the levels (nerves) was the third occipital nerve. I ask if you choose 64640 for the TON. They came back and said they might have to burn over a wider area, but when they provided the coding they did not separately code the TON and stating it was part of the C3 medial branch. Trying recall the best of how it was stated and my interpretation is they don't feel that TON should be 64640 and they don't feel you should bill a separate level using the facet or RF codes. When this is a non-neurolytic medial branch block it seemed like double counting and it makes sense this is their response even though the physician's might feel they are doing extra work and should be paid for it. I have not had a chance to go over with the physician in the group that usually performs this type of procedure that encompasses the TON.

  10. Default
    OMG that makes alot of sense. I like you think the provider does the extra work so he not necessarily over charges but want to be paid for the work that he does. What great information that you have provided. Thanks so very much. And, I am sure I will need your help in the near future.

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