Pulsed RF for lumbar radicular pain

[drusso]

I'm on the verge of being talked into trying this on a patient who is *CONVINCED* it will work because his FRIEND had it done by a pain doctor in Arizona and it worked amazingly well for him....The patient has had waning results from TFESI's.

I've never actually done it, but it seems easy enough...basically a TFESI with a RF probe, right? Any pearls, hard lessons learned, or thoughts about the topic? I guess pulsed is the way to go if you really don't want to destroy something, but just annoy it a little??

...my default idea is to just tell him to go to Arizona!

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[Tenesma]

have done it - mixed results - stopped doing them...

my RF needle is too sharp (sharper than regular quinke) so i would go with the blunt ones...

the issue w/ pulsed RF as Gorback so eloquently pointed out is the difficulty in measuring true voltage/temperature at the needle tip, and the high likelihood that even though you may set a temp of 42 degrees you may be generating up to 60-65 degrees at the needle tip.... this has some potentially disastrous consequences...

in europe this is done more often - but they also put lido and steroid on DRG, so which is really doing the trick?

 

[ampaphb]

have done it - mixed results - stopped doing them...

my RF needle is too sharp (sharper than regular quinke) so i would go with the blunt ones...

the issue w/ pulsed RF as Gorback so eloquently pointed out is the difficulty in measuring true voltage/temperature at the needle tip, and the high likelihood that even though you may set a temp of 42 degrees you may be generating up to 60-65 degrees at the needle tip.... this has some potentially disastrous consequences...

in europe this is done more often - but they also put lido and steroid on DRG, so which is really doing the trick?

T:

If the patient as already gotten only short-term relief from multiple TFESIs in the past, why would you postulate that the long-term relief a patient might theoretically obtain s/p PRF would be due to the steroid and local?

 

[Mister Mxyzptlk]

There's only marginal evidence that PRF works for radiculopathy. I abandoned it a long time ago for radicular pain. There is an RCT looking at PRF-DRG for lumbar radiculopathy in Pain Physician in the past few months. It is a fine example of how bad an RCT can be.

It took me 2 slides at the ISIS meeting just to summarize all the flaws - like not presenting their data in the paper, only the abstract. What do those editors smoke?

 

[Tenesma]

who said anything about long-term control????

 

[kmart]

Loved your talk in Vegas on PRF, Gorback.

Given the inaccurate needle tip readings with PRF, does anyone have case reports or other data on negative outcomes?

I've done it about 8 times for people who are miserable with lumbar radicular pain and no other options (Failed transforaminal, multiple antiepileptics, non-surgical, failed stim or to risky due to comorbidity, etc.) Only 2 got sufficient relief for more than 3 months. By traditional measures, even their relief was poor (30-40% change on VAS), but they were both very clear that it made a tremendous difference in function.
I repeated those two when the pain returned with similar results.

In my small series, that leaves me with:
A procedure with a high number needed to treat that works at about a placebo rate and I can't get paid for it. But what about those two it helped gert back up and at least able to go to the store and socialize. Are they continuing to respond to a placebo procedure multiple times for 3-4 months?

What's a guy to do?

 

[Doctodd]

why didnt u get paid for it?......is the pulsed code different than the regular rf code? If the only reason is fraud, which i dont define this as such, i dont see a reason to use generic 64999 vs 64622 and 64623. I could be wrong though, and thats why im here ;-)

T

 

[Formication]

64623. Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level

1) What am I "destroying"? Based on the inaccuracy of the needle tip data maybe I am; but I sure don't intend to with PRF. If I did , I would use heat like a good little Bogdukian.

2) For radicular pain, I do this at the DRG, so I'm not treating the "paravertebral facet nerve."

3) I over-stated my case. I did get paid something. I billed a good ole 64483 and got my standard epidural reimbursement. I ate the cost of the needle and the extra 4 minutes. I could have had the patient sign an advanced benificiary notice and made them pay for it themselves. Anybody doing this?

4) I know some people who stil bill a 62282. Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal). Just thought I would point that radiofrequency isn't even in this code anymore.

 

[Formication]

64623. Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level

1) What am I "destroying"? Based on the inaccuracy of the needle tip data maybe I am; but I sure don't intend to with PRF. If I did , I would use heat like a good little Bogdukian.

2) For radicular pain, I do this at the DRG, so I'm not treating the "paravertebral facet nerve."

3) I over-stated my case. I did get paid something. I billed a good ole 64483 and got my standard epidural reimbursement. I ate the cost of the needle and the extra 4 minutes. I could have had the patient sign an advanced benificiary notice and made them pay for it themselves. Anybody doing this?

4) I know some people who stil bill a 62282. Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal). Just thought I would point that radiofrequency isn't even in this code anymore.

 

[Mister Mxyzptlk]

We heard you the first time.

 

[Pacman27]

Any one doing this at all

I have a patient who I am thinking of doing this for, but have never done Pulsed TF

He had a previous lami at the L4/5 level but now has severe radicular pain at the L4 level

1 t 2 days of pain free with saline and dex TFESI

He really wants to avoid surgery and / or stim

any thoughts

Thanks

 

[lonelobo]

Any one doing this at all

I have a patient who I am thinking of doing this for, but have never done Pulsed TF

He had a previous lami at the L4/5 level but now has severe radicular pain at the L4 level

1 t 2 days of pain free with saline and dex TFESI

He really wants to avoid surgery and / or stim

any thoughts

Thanks

Did some in training with mixed results, question as before with previous posts is how are you going to bill pulsed RF(legally)?

 

[DOctorJay]

probably just bill as a SNRB no?

 

[Pacman27]

I am not too worried about the billing. Truthfully I will eat the cost if I have to. I know its a poor business move, but I am doing okay

I will try to bill it as a 64483

I dont want to cause any harm, so I have to be sure the risk outweights the benefits

He has failed SCS in the past by another provider in the area

 

[lonelobo]

I am not too worried about the billing. Truthfully I will eat the cost if I have to. I know its a poor business move, but I am doing okay

I will try to bill it as a 64483

I dont want to cause any harm, so I have to be sure the risk outweights the benefits

He has failed SCS in the past by another provider in the area

If you are not too worried about billing it, why are you going to bill as a 64483?
What are you going to dictate in your note?
You going to leave out the pulsed RF part of the procedure and just dictate a TESI?

 

[Stim4me]

If you are not too worried about billing it, why are you going to bill as a 64483?
What are you going to dictate in your note?
You going to leave out the pulsed RF part of the procedure and just dictate a TESI?

Agree, you will not get paid, your dictation with not match your billing code, and if you cause damage its experimental by all insurances and an attorneys wet dream... Lose lose senario

 

[Doctodd]

Is it fraud if he did and billed for an esi, and then did the rf for free?

 

[lobelsteve]

Is it fraud if he did and billed for an esi, and then did the rf for free?

If he also bills the throw away experimental code i think he is fine. But would get denied payment as they would denyvthe tfesi at time of experiment and dent payment for experimantal procedure

 

[Stim4me]

Is it fraud if he did and billed for an esi, and then did the rf for free?

Fraud is a tough word. But yes you cannot perform a procedure and undercode it. Cms is strict about this. An unlisted code is best, although it won't be paid. United Hc redid their epidural criteria and rfa criteria, and they hate anything that is "pulsed"... Just have the patient sign a waiver and do it

 

[ampaphb]

Just a thought, but could the OP dictate two procedure notes, one for the tfi, the other for the pulsed rf? That way, he could then chose to not submit on the prf, and still document what he did accurately?

 

[lonelobo]

So if you go ahead and do both a pulsed RF and TESI at the same time, how will you really know which one is efficacious?

 

[NOSfan]

Page 10 of the 2014 CCI General Correct Coding Polices.

Revision Date: 1/1/2014

CHAPTER I GENERAL CORRECT CODING POLICIES FOR NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES

Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the physician must report this code rather than report a less comprehensive code with other codes describing the services not included in the less comprehensive code. For example if a physician performs a unilateral partial mastectomy with axillary lymphadenectomy, the provider should report CPT code 19302 (Mastectomy, partial…; with axillary lymphadenectomy). A physician should not report CPT code 19301 (Mastectomy, partial…) plus CPT code 38745 (Axillary lymphadenectomy; complete).
Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. For example, if a physician performs a superficial axillary lymphadenectomy (CPT code 38740), the physician should not report CPT code 38745 (Axillary lymphadenectomy; complete).

 

[emd123]

I know it is technically not allowed, but does anyone know of even a single case of a physician arrested or otherwise sanctioned in even the slightest way for downcoding/under-charging charts?

 

[Doctodd]

If he also bills the throw away experimental code i think he is fine. But would get denied payment as they would denyvthe tfesi at time of experiment and dent payment for experimantal procedure

No i mean if he bills for the tfesi only....he does the rf for free/doesnt bill it.

 

[Ducttape]

I know it is technically not allowed, but does anyone know of even a single case of a physician arrested or otherwise sanctioned in even the slightest way for downcoding/under-charging charts?

Do you want to be the first?

 

[emd123]

Do you want to be the first?

You're funny

 

[Pacman27]

Come on answer the original question

I will charge the patient $1 for the pulsed rfa as that is my cost and just bill for the TFESI

I know it will not be the TFESI as I have done 2 now and he gets about 1 to 2 days of excellent relief and the pain comes back. On the table I am able to reproduce his pain

 

[ampaphb]

Q1 of '16 St. Jude will have a stim for the DRG

 

[olafa]

I'm on the verge of being talked into trying this on a patient who is *CONVINCED* it will work because his FRIEND had it done by a pain doctor in Arizona and it worked amazingly well for him....The patient has had waning results from TFESI's.

I've never actually done it, but it seems easy enough...basically a TFESI with a RF probe, right? Any pearls, hard lessons learned, or thoughts about the topic? I guess pulsed is the way to go if you really don't want to destroy something, but just annoy it a little??

...my default idea is to just tell him to go to Arizona!

I do it, we get good results if you want to send him down to me we can take care of it. FWIW It is reasonable step between ESI not lasting and consideration for stim (obviously more invasive) some patients do like the minimally invasive approach better- defer stim to when absolutely needed and getting good outcomes doing it this way. nothing to loose really, if DRG RF doesnt work then can always try SCS.
Correct way is 64999- unlisted / can do ESI in combo for any neuritis that may be post procedure and as far as knowing which worked. Clearly the first couple ESIs did not last much why would another be any different, the difference in the treatment is the additional DRG-RF. The key is close proximity to the DRG measured with minimum sensory threshold prior to stim.

 

[bedrock]

Epidural guy-
I think you've done a lot of these, based on some of your older posts? Can you elaborate on your success rate and your technique?

 

[epidural man]

I would try it - absolutely...there is very LITTLE downside. NNH is way higher than NNT.

I don't have any pearls, other than I try to follow placement described in Sluijter's RadioFrequency book (DRG sits differently at each level from L1 to L5), and I would pulse the SHEEEET out of it -meaning, I go to 45C (not 42C) and for as long as you can stand it (4-10 minutes). I don't use local before treatment so if temp is increasing, the patient should be able to tell me this.

Reason to use 45C.
1. My machine will not hold voltage constant. Since voltage is the key in a good treatment, I want a higher temp to give a higher voltage. If you have a constant voltage capability, pick whatever temp you want I suppose. I know some people (think Simopoulus at Beth Israel) that will use even higher temp on the DRG.