Source : Neurology & Pain Management Coding Alert
Pain Management: Avoid Denials by Correctly Counting Injections for Spinal Radiofrequency
Plus: Verify how each payer wants bilateral procedures reported.
Reporting spinal radiofrequency (RF) changed in 2012 because of implementation of new CPT® codes and descriptors. Our experts share the top three things you need to remember so you'll submit accurate claims.
Know the New Codes
CPT® 2012 deleted four codes for paravertebral facet joint nerve destruction (64622, 64623, 64626, and 64627). According to AMA CPT® Changes 2012, "Four new codes have been established to more accurately reflect the work and anatomical site involved in these procedures." Your new code options are:
64633 -- Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
64634 -- ... cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)
64635 -- ... lumbar or sacral, single facet joint
64636 -- ... lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure).
Rationale: Providers perform most paravertebral facet joint services with some type of imaging guidance. Therefore, including "imaging guidance" in the descriptor makes sense.
Change Your Counting Perspective
While the previous destruction codes addressed levels, codes 64633-64636 address individual joints.
"Prior to 2012, the unit of service used to report these procedures was a single nerve at a single vertebral level," states AMA. Take a closer look at 64633-64636 and you'll see that "The unit of service is a single facet joint ... rather than a vertebral level."
Meaning: Now when you code RF of the paravertebral facet joints, focus on counting joints instead of nerves.
Example: "In 2011, if a physician documented that he performed RF at C3-C6 you would code for C3, C4, C5, and C6 paravertebral facet joint nerve destruction separately for a total of four," says Kyle Shupe, with Medical Billing, Inc., in Ankeny, Iowa. These four medial branches provide the sensory innervation to the C3-C4, C4-5 and C5-C6 paravertebral facet joints. In 2012, the code descriptor reads "single facet joint," so now you report a total of three facet joint levels or 64633 with one unit of service and 64634 with two units of service.
The same holds true for coding in the lumbar region. If the procedure note indicates RF ablation of the L3 and L4 medial branches and the L5 dorsal ramus, report 64635 with one unit of service and 64636 with one unit of service. These three paravertebral facet joint nerves provide innervation to the L4-L5 and L5-S1 facet joints.
Careful: When coding these injections, verify whether you're reporting anatomic locations of the injections or medial branches. "It can be different scenarios, based on how it's documented," says David Waldman, CPC, CPC-H, with The Headache and Pain Center in Overland Park, Ks. "It can be anatomical location or medial branches, and that can affect which facet levels are being treated."
Watch for Bilateral Opportunities
Note that the code descriptors for 64633-64636 apply to "nerve(s)." That means a code can represent destruction by either a single nerve injection or multiple injections to that joint. If your provider injects both nerves at a single level you won't report multiple codes -- but you will need to report the service as a bilateral procedure. Similar to the codes for paravertebral facet joint injections, CPT® considers these new codes to report unilateral procedures. If a physician performs RF destruction of the paravertebral facet joint nerves of both the right and left facet joints at the same level, this should be reported as bilateral. For example, if a physician performed RF ablation to the right and left C5 medial branch and also the right and left C6 medial branch, this would be reported as a single level (C5-C6) bilaterally.
Many payers request that you append modifier 50 (Bilateral procedure) to the CPT® code to designate a bilateral procedure. Verify whether this is the case for your payer in question, however.
Example: Some payers do not accept modifier 50 in this situation. "When you use the 50 modifier for a bilateral procedure for one of our payers, the payer will deny the claim for invalid modifier use," says Linda Katicich, facility manager for Tallahassee Neurological Clinic's division of pain management. "For some reason, they want each injection on a separate line item."