Cervical MBNB billing

[painfree23]

can someone please help? I'm trying to figure out how to bill for cervical MBNB. I did it in fellowship, but my coworkers here are trying to tell me something different..tried finding some stuff online but it was kind of hard to find a definite answer

If I do bilateral C4-C6 medial branch nerve blocks (diagnostic) --- is that 64490,64491 and 64492 with a -50 modifier?

Or do you bill for two (64490, 64491) , since technically you are only dennervating two facet joints?

With the modifier -50 , do you usually get reimbursed the same amount on each side?

Same question for RF. Thanks so much.

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[lonelobo]

can someone please help? I'm trying to figure out how to bill for cervical MBNB. I did it in fellowship, but my coworkers here are trying to tell me something different..tried finding some stuff online but it was kind of hard to find a definite answer

If I do bilateral C4-C6 medial branch nerve blocks (diagnostic) --- is that 64490,64491 and 64492 with a -50 modifier?

Or do you bill for two (64490, 64491) , since technically you are only dennervating two facet joints?

With the modifier -50 , do you usually get reimbursed the same amount on each side?

Same question for RF. Thanks so much.

64490,64491 50 modifier
same applies to RF

 

[DOctorJay]

you bill per joint with the -50 modifier

no you don't get reimbursed same amount for each side, most typically bring back 10 days after the first RFA to do the other side

 

[unchockey21]

What they said... I’ve only done bilateral RF once for a hemophiliac.

 

[SSdoc33]

What they said... I’ve only done bilateral RF once for a hemophiliac.

i do bilaterals all the time b/c i think it is inhumane to have a patient come in for 6 separate injection visits. not to mention the follow ups in between.

 

[DOctorJay]

bilateral MBBs
pain diary sent home with pt
they fax, mail, drop off - if appropriate schedule RFA
RFA one side at a time 2 weeks apart
follow up 6 weeks after first RFA

 

[painfree23]

64490,64491 50 modifier
same applies to RF

Yea this how we did it in fellowship...

So if you do one sided cervical RF ...ur physician fee barely covers the RF needles (need 3) Also do most of you just do C4-C6??

What about lumbar billing? Assuming its the same ...3 medial branches (L4,L5,S1) only covers 2 facets. Are most of you just doing the L4-S1 or going up to L3 too?

 

[SSdoc33]

bilateral MBBs
pain diary sent home with pt
they fax, mail, drop off - if appropriate schedule RFA
RFA one side at a time 2 weeks apart
follow up 6 weeks after first RFA

your insurers only require 1 mbb?
you always get back the "pain diary"?
your patients actually understand the rationale' behind a diagnostic MBB?

 

[SSdoc33]

Yea this how we did it in fellowship...

So if you do one sided cervical RF ...ur physician fee barely covers the RF needles (need 3) Also do most of you just do C4-C6??

What about lumbar billing? Assuming its the same ...3 medial branches (L4,L5,S1) only covers 2 facets. Are most of you just doing the L4-S1 or going up to L3 too?

watch your nomenclature. you are getting it all wrong

 

[painfree23]

watch your nomenclature. you are getting it all wrong

Yea this how we did it in fellowship...
*corrected* (thanks)

So if you do one sided cervical RF ...ur physician fee barely covers the RF needles (need 3) Also do most of you just do C4-C6 MBNB?

What about lumbar billing? Assuming its the same ...3 medial branches (L4,L5,S1 MBNB) only covers 2 facets. Are most of you just doing the L4-S1 MBNB or going up to L3 MBNB too?

 

[DOctorJay]

your insurers only require 1 mbb?
you always get back the "pain diary"?
your patients actually understand the rationale' behind a diagnostic MBB?

I missed a step, if first one is appropriate we schedule MBB#2 (I always do 2). I almost always get the diary back. I educate my patients very thoroughly when I discuss the rationale for MBBs, and no they don't always understand but it's usually enough to figure out if the blocks were successful. In rare instances I will bring patients back for follow up to review further.

 

[pastafan]

We have them call the next day with results of pain diary. Too many are lost and details forgotten otherwise. If appropriate then second set of blocks is scheduled. If not appropriate then follow-up visit.

 

[unchockey21]

i do bilaterals all the time b/c i think it is inhumane to have a patient come in for 6 separate injection visits. not to mention the follow ups in between.

Unilateral RF. All of the MBBs are bilateral. So 4 injection visits.

 

[unchockey21]

Yea this how we did it in fellowship...
*corrected* (thanks)

So if you do one sided cervical RF ...ur physician fee barely covers the RF needles (need 3) Also do most of you just do C4-C6 MBNB?

What about lumbar billing? Assuming its the same ...3 medial branches (L4,L5,S1 MBNB) only covers 2 facets. Are most of you just doing the L4-S1 MBNB or going up to L3 MBNB too?

Lumbar and thoracic billing are the same. Do the levels they have pain. Look at referral patterns. Examine under fluoro.

 

[Ducttape]

Lumbar and thoracic billing are the same. Do the levels they have pain. Look at referral patterns. Examine under fluoro.

To nit pick...

Cervical and thoracic mbb have same billing code 64490/64491 and lumbar is 64493/64494...

 

[painfree23]

To nit pick...

Cervical and thoracic mbb have same billing code 64490/64491 and lumbar is 64493/64494...

Yea my question was basically in ur protocol do most of you just do 64490/91 - 50 modifier, or are you doing 64490/91/92

 

[unchockey21]

To nit pick...

Cervical and thoracic mbb have same billing code 64490/64491 and lumbar is 64493/64494...

Sorry for any confusion. I meant in regards to billing based on # of joints denervated. Good catch.

 

[Tapspatellas]

bilateral MBBs
pain diary sent home with pt
they fax, mail, drop off - if appropriate schedule RFA
RFA one side at a time 2 weeks apart
follow up 6 weeks after first RFA

I will generally do 3-4 weeks for contralateral side RFN personally, gives time for neuritis to improve should they get it. I almost never do bilateral RFN at same time because, in no particular order:
1. Time (to do properly)
2. If bilateral neuritis develops
3. Neck weakness
4. Ataxia if doing TON.

I also find that some of my patients had a worst side, and the contralateral side isn't bothering enough to do anything about after the first RF.

 

[clubdeac]

Yeah doing a bilateral cervical RF is brutal for me and the patient. Seems to take forever and I've had a couple patients come back complaining of neck weakness or ataxia. I therefore only do one side at a time; reassess and then do second burn

 

[painfree23]

Yeah doing a bilateral cervical RF is brutal for me and the patient. Seems to take forever and I've had a couple patients come back complaining of neck weakness or ataxia. I therefore only do one side at a time; reassess and then do second burn

How many medial branches are you doing on those you got weakness/ataxia?

 

[Tapspatellas]

How many medial branches are you doing on those you got weakness/ataxia?

Ataxia only takes a single TON to develop, but usually dual TON more likely. Weakness at least 2 levels. I had a 3 level bilateral patient who I inherited and convinced me to do both at same time due to insurance issues coming up. She was weak feeling substantially for 3 weeks with 6 weeks to resolution. No ataxia. Was sore as h€ll for a couple weeks too. I warned her well before the procedure.

 

[Ducttape]

I do as many as 2 levels bilaterally, but rarely carpet burn by doing 3 levels on one side. so only 64490&64491, or 64493&64494. +/- mod 50.

 

[clubdeac]

How many medial branches are you doing on those you got weakness/ataxia?

3 levels bilaterally

 

[painfree23]

i'm having trouble getting a good lateral image for C6 lateral body. Arms are tucked. I'm doing these prone, any suggestions?

 

[Tapspatellas]

i'm having trouble getting a good lateral image for C6 lateral body. Arms are tucked. I'm doing these prone, any suggestions?

Modified swimmers if doing lateral decube, ala Taus. Otherwise if supine (my fav position for MBB) or prone for RFA or some MBB, I’ll translate down the c arm and collimate tight on the area and I can usually get a decent view of the pillar and needle tip.

 

[Taus]

Modified swimmers if doing lateral decube, ala Taus. Otherwise if supine (my fav position for MBB) or prone for RFA or some MBB, I’ll translate down the c arm and collimate tight on the area and I can usually get a decent view of the pillar and needle tip.

. My paper on this will finally be published in a few months. I have yet to find c7 I couldn’t see on lateral with a modified swimmers.

 

[painfree23]

. My paper on this will finally be published in a few months. I have yet to find c7 I couldn’t see on lateral with a modified swimmers.

Did u publish this yet? Would love to see it!

How do u guys decide on which cervical mbnbs to hit. example : PT with C3-C6 spondylosis, moderate facet arthopathy at all levels with headaches and shoulder pain.

 

[Taus]

http://www.painphysicianjournal.com/current/pdf?article=NTIxMg==

It’s finally out. Hope readers find it helpful!

 

[nvrsumr]

Like it. Will try on my next thick neck person. Thanks!

 

[drusso]

http://www.painphysicianjournal.com/current/pdf?article=NTIxMg==

It’s finally out! Hope readers find it helpful.

Great job! I've stumbled on this myself, but never codified/standardized it...mostly just making the MA move the patient around on the table so I could see better what I was doing. I will be using this as my standard positioning now.

 

[painfree23]

Do you all do lateral positioning for mbnb?

 

[lobelsteve]

Prone.

 

[painfree23]

Prone.

How do u see the lower cervical facets for that

 

[lobelsteve]

Rotate the c. Pillar view, colimate.

 

[drrosenrosen]

Supine, lateral to medial approach for MBB. Prone, posterior to anterior for RF

 

[painfree23]

Supine, lateral to medial approach for MBB. Prone, posterior to anterior for RF

Why two different views?

 

[drrosenrosen]

idk, just how I was trained. I look at it as similar to lumbar mbb vs rf. For the branch block, you just care about getting close enough to get a blob of local on the nerve. For the RF you really want to lay the active tip as parallel to the nerve as possible, so you end up with different angles.

 

[EruditeDoc]

For those who use the Stryker Venom, do you do your RF in the lateral decub position? Even for those who do not, any success doing in the lateral position?

 

[drrosenrosen]

I use Venom and do it prone posterior approach, but most of the procedure is spent with C-arm in lateral

 

[painfree23]

I use Venom and do it prone posterior approach, but most of the procedure is spent with C-arm in lateral

In the posterior prone approach, are u straight ap or do you oblique to the side you are doing as furman suggests?

 

[drrosenrosen]

I do straight AP, but I haven't changed my technique in a long time. I've been looking at ways I can improve my technique and adjust my fluoro views.

 

[painfree23]

I do straight AP, but I haven't changed my technique in a long time. I've been looking at ways I can improve my technique and adjust my fluoro views.

I do straight AP, sometimes add some cranial tilt. Furman describes a technique with some oblique too.