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Gina Posted Thu 10th of January, 2019 12:09:15 PM
I have 2 scenarios with a question on frequency of billing the RFA codes 64635/64636 and how to apply the Medicare's LCD for both scenarios. LCD's limitation of coverage states below. • For each covered spinal region (cervical/thoracic or lumbar), no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session, e.g., two (2) bilateral levels or four (4) unilateral levels. • Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced ≥ 50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months. Scenario 1: Provider did an RFA on 3 levels L3-4, L4-5, L5-S1 on the RT side and do the same on LT side a week or 10 days after. These are being billed with 64635-RTx1, 64636-RTx2 then with 79,LT for the other side. After 6 mos, the prov will repeat the RFAs on same levels doing one side then the other side. On the 1st RFA treatment would you apply the maximum of 2 RF session being met because we have submitted the code 64635/64636 twice? We can also interpret this as not meeting the max of 2 because only one RF treatment was done per side correct? This is how the provider is interpreting it because he knows he is allowed to repeat RFA on the same joint. Scenario 2: Provider did an RFA on 3 levels L3-4, L4-5, L5-S1 on the RT side and do the same on LT side a week or 10 days after. These are being billed with 64635-RTx1, 64636-RTx2 then with 79,LT for the other side. A few months later, the prov will do RFAs on different levels in the same spinal region-lumbar. How would you apply the LCD in this case if they only allow a maximum of 2 RF sessions in each spinal region within 12 rolling months? In the LCD, do you interpret the max of 2 thermal sessions for both sides and for all levels w/in the spinal region and should this be applied per cpt code not per per side, per level? Please note, other carriers are clear with their limitation of coverage with max of 2 RFA per level, per side in a year, so both scenarios are okay to bill. Thank you
SuperCoder Answered Fri 11th of January, 2019 07:53:20 AM

CPT 64635 has allowable unit 1 and CPT 64636 have allowable units 4, so total allowable units are 5 per date of service (DOS). Hence as per CMS maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per year in the cervical/thoracic spine and five (5) in the lumbar spine.

Scenario 1: Since, you have billed one unit of 64635 and 2 units of 64636 on the right side on same date of service (DOS) will be paid easily, however when you are billing for left side within the 10 days (Global Period of 64635) then again total 5 units can be billed with the supportive modifier as per patient's condition, like modifier 58 (as staged or related procedure) or modifier 78 (unplanned return to operating room) can be used. Modifier 79 will not be supportive as it is for unrelated procedure, which is not correct in your case. Make sure to provide the reason, why you did not perform the procedure together for RT and LT side and also provide the medical necessity to support the LT side procedure.

Also, when you are performing the procedure on the same level/joint and if you are bounded to follow the LCD guidelines, then stick with repeat denervation procedure guideline "Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced ≥ 50% improvement of pain and improvement in patient specific ADLs documented for at least 6 months", means it should be documented that patient has improved ≥ 50% of pain and specific ADLs for at least 6 months.

Scenario 2: Again, billed 3 levels on RT is fine, but when billing LT side, considering 10 days global period, if it is done within 10 days then append modifier and if it after 10 days then need not to append the modifier and all 5 units can be billed with supportive medical necessity. As per general medical coding guidelines, when procedure is performed on the different levels in same region, then it can be billed simply without the modifier, just need to provide the reason for procedure.

On the other hand, if LCD only allowed maximum of 2 RF sessions in each spinal region then it will be CPT based, but not region based, because the payment will be on the basis of procedure performed. It is suggested to read the policy thoroughly and bill the codes accordingly.

Hope this helps!

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