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Facet MBB and Rf coding/billing

emd123

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    Informal poll:

    For a facet mbb, with three needles placed for example and L4, L5, and S1/ala what do you code that?

    64493 and 64494 and 64495 (3 levels, 3 needles)

    or

    64493, and only 64494 (3 needles, but only 2 joints, blocking nerve above and nerve below to block a joint)?

    Same question for Rf. If 4 needles are placed, levels L3, L4, L5, and S1/ala, what do you code that?

    64635 and 64636 (one, two or 3 units)?
     

    lobelsteve

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    1. Attending Physician
      Informal poll:

      For a facet mbb, with three needles placed for example and L4, L5, and S1/ala what do you code that?

      64493 and 64494 and 64495 (3 levels, 3 needles)

      or

      64493, and only 64494 (3 needles, but only 2 joints, blocking nerve above and nerve below to block a joint)?

      Same question for Rf. If 4 needles are placed, levels L3, L4, L5, and S1/ala, what do you code that?

      64635 and 64636 (one, two or 3 units)?

      MBB is 64493, 64494, 64495 for 3 to 31 levels.
      RF is 64494 for 1st joint (2 levels), 64495 (for each additional joint). This could be 1 nerve each for contiguous segments.

      L2-L5 RF sites on TP/SAP junction is 64494, 64495 x2, and fluoro 77003 (for now)
       

      stim4u

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        fluro is bundled for facet/MBB and RFA codes.
        Use of 77003 is considered fraudulent.
        SI injection are also bundled, so no 77003.
        Only 62311/10 are compatible with 77003 for the last year.
         
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        SSdoc33

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        1. Attending Physician
          Informal poll:

          For a facet mbb, with three needles placed for example and L4, L5, and S1/ala what do you code that?

          64493 and 64494 and 64495 (3 levels, 3 needles)

          or

          64493, and only 64494 (3 needles, but only 2 joints, blocking nerve above and nerve below to block a joint)?

          Same question for Rf. If 4 needles are placed, levels L3, L4, L5, and S1/ala, what do you code that?

          64635 and 64636 (one, two or 3 units)?

          very difficult to answer when your nomenclature is wrong.

          I assume your first example is for an MBB of the L4-5 and L5-S1 Z-joint on one side only? This would be a L3 and L4 medial branch block and L5 dorsal ramus block. The L5 dorsal ramus runs at the ala. Not sure where you are pulling S1 from. If this is indeed what you mean for a medial branch block, then it would be a 2 level code. If you RF this, it would also be a 2 level code.
           

          lobelsteve

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          1. Attending Physician
            fluro is bundled for facet/MBB and RFA codes.
            Use of 77003 is considered fraudulent.
            SI injection are also bundled, so no 77003.
            Only 62311/10 are compatible with 77003 for the last year.

            Nope. Fluoro in my LCD is allowed for RF and ILESI.
             

            SpineBound

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            1. Attending Physician
              Informal poll:

              For a facet mbb, with three needles placed for example and L4, L5, and S1/ala what do you code that?

              64493 and 64494 and 64495 (3 levels, 3 needles)

              or

              64493, and only 64494 (3 needles, but only 2 joints, blocking nerve above and nerve below to block a joint)?

              Same question for Rf. If 4 needles are placed, levels L3, L4, L5, and S1/ala, what do you code that?

              64635 and 64636 (one, two or 3 units)?
              I read the medicare guideline and they call it destruction of nerve/joint. This is confusing to me as well because the number of nerves = joints + 1. NOT #nerves = #joints.

              If its ambiguous then bill for each nerve. Right?
               

              DOctorJay

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                very difficult to answer when your nomenclature is wrong.

                I assume your first example is for an MBB of the L4-5 and L5-S1 Z-joint on one side only? This would be a L3 and L4 medial branch block and L5 dorsal ramus block. The L5 dorsal ramus runs at the ala. Not sure where you are pulling S1 from. If this is indeed what you mean for a medial branch block, then it would be a 2 level code. If you RF this, it would also be a 2 level code.

                This is correct. You bill now for each joint treated, not nerve blocked or ablated.
                 

                emd123

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                  very difficult to answer when your nomenclature is wrong.

                  I assume your first example is for an MBB of the L4-5 and L5-S1 Z-joint on one side only? This would be a L3 and L4 medial branch block and L5 dorsal ramus block. The L5 dorsal ramus runs at the ala. Not sure where you are pulling S1 from. If this is indeed what you mean for a medial branch block, then it would be a 2 level code. If you RF this, it would also be a 2 level code.

                  You spelled out the anatomy perfectly. Thank you. However, the CPT descriptor is not anatomically perfect, but is very ambiguous and says this, "Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral."

                  http://www.asipp.org/documents/Physcians2013Final.pdf

                  You can describe the procedure in three ways, I suppose, depending on whether you describe what vertebral body the needle is placed at, which medial branch nerve you are blocking, or which joints innervation you are affecting. Making it even more vague is that you block a nerve, not a joint. That's why it's called a medial branch nerve block, not "joint block" and neurolysis, not "joint lysis." You neurolyse a nerve not a joint. To me it's vague and I suppose the responses prove this, considering we already have several different interpretations of how to code this, in as many responses.
                   

                  bedrock

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                    Nope. Fluoro in my LCD is allowed for RF and ILESI.

                    Sorry, but that is definitely wrong and you've been billing fraudently for almost two years.
                    Fluoro was bundled into the RF code when the RF was changed from by nerve to by joint billing in January 2012.

                    Fluoro is bundled for TFESI, SIJ, SCS, MBB, and RF.
                    Fluoro can still be billed for ILESI and sympathetic blocks.
                     

                    Ducttape

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                      agree with bedrock on fluoro. only ILESI and sympathetic blocks.

                      to emd - while the terminology is confusing, on the asipp documents, it is fairly clear otherwise by CMS.

                      From CMS:

                      An injection may be placed in the facet joint itself or around the medial branch nerve innervating the joint. In general, it is believed that two to three medial branch nerves innervate each lumbar facet joint and two nerves innervate each cervical or thoracic facet joint. These nerves are the branches of the posterior division of the spinal nerves, located immediately above and below the joint. The CPT codes 64490 and 64493 are intended to be used to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve. Likewise, CPT codes 64491, 64492 and 64494, 64495 are intended to report second and third additional levels paravertebral facet joints and not each additional nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them as defined by the AMA CPT Committee.
                       

                      Pain Applicant1

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                        Agree, fluoro is definitely bundled into CPT code for RF and MBB:

                        Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

                        Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level


                        LCD shouldn't really influence a clearly defined CPT code as above.

                        Also, if you block or burn 4 levels you should bill 3 codes. If you block or burn 3 levels you should bill only 2 codes.
                         

                        SpineBound

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                        1. Attending Physician
                          You spelled out the anatomy perfectly. Thank you. However, the CPT descriptor is not anatomically perfect, but is very ambiguous and says this, "Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral."

                          http://www.asipp.org/documents/Physcians2013Final.pdf

                          You can describe the procedure in three ways, I suppose, depending on whether you describe what vertebral body the needle is placed at, which medial branch nerve you are blocking, or which joints innervation you are affecting. Making it even more vague is that you block a nerve, not a joint. That's why it's called a medial branch nerve block, not "joint block" and neurolysis, not "joint lysis." You neurolyse a nerve not a joint. To me it's vague and I suppose the responses prove this, considering we already have several different interpretations of how to code this, in as many responses.

                          This is why I bill for each nerve and not each joint. Am I doing something wrong?
                           

                          bedrock

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                            This is why I bill for each nerve and not each joint. Am I doing something wrong?

                            Got to remember that those descriptions were originally written pre 2009. Before 2009 when MBB/facet joints were bundled, and 2012 when RF was bundled, the coding was by nerve instead of by joint. So that's how the description was written, which is why it looks confusing to read it now that everything has been bundled.

                            For lumbar facet joint procedures the terminology is very clear.

                            L3 medial branch, L4 medial branch, L5 dorsal ramus= 2 joints
                            2 lumbar facet joint block or two lumbar facet joint RF (L4-L5, L5-S1 facet joints).

                            L2 medial branch, L3 medial branch, L4 medial branch, L5 dorsal ramus = 3 joints
                            3 lumbar facet joint block or 3 lumbar facet joint RF (L3-L4, L4-L5, L5-S1 facet joints)
                             
                            Last edited:

                            Ducttape

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                              This is why I bill for each nerve and not each joint. Am I doing something wrong?

                              You are treating the joint and not the nerve. The nerve(s) is an innocent bystander because of all the complaining that the joint does. It's facet arthropathy, not median branch neuralgia, that is the diagnosis.
                               

                              bedrock

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                              1. Attending Physician
                                Informal poll:

                                For a facet mbb, with three needles placed for example and L4, L5, and S1/ala what do you code that?

                                64493 and 64494 and 64495 (3 levels, 3 needles)

                                or

                                64493, and only 64494 (3 needles, but only 2 joints, blocking nerve above and nerve below to block a joint)?

                                Same question for Rf. If 4 needles are placed, levels L3, L4, L5, and S1/ala, what do you code that?

                                64635 and 64636 (one, two or 3 units)?

                                Getting back to the OP's question. Burning S1 doesn't get you paid more if you're trying to do MBB or RF for lumbar facet joints.

                                The majority of pain physicians (and ISIS), believe that denervating the L4-L5, L5-S1 facet joints is accomplished by RF on the the L3 medial branch, L4 medial branch, and L5 dorsal ramus. For this you can code 64635 X1 and 64636 X 1.

                                If you belong the the old school that believe that S1 also supplies the L5-S1 facet joint, and so you do S1 lateral branch RF as part of your RF for the L4-L5, L5-S1 facet joints, you can still only bill for 2 facet joint RF.

                                Before 2012, you got paid more by doing S1 lateral branch in this situation, because you were paid by nerve, not by joint. (Got paid for burning 4 nerves not just 3 nerves, if you did L4-L5, L5-S1 facet joint RF that included the S1 lateral branch). Similarly before 2009 you got paid for 4 nerves when doing MBB, if you included S1.

                                Now that we're paid by joint when doing lumbar facet joint MMB/RF, if you decide the block/burn the S1 lateral branch, you're doing it for free.
                                 
                                Last edited:

                                SpineBound

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                                  Got to remember that those descriptions were originally written pre 2009. Before 2009 when MBB/facet joints were bundled, and 2012 when RF was bundled, the coding was by nerve instead of by joint. So that's how the description was written, which is why it looks confusing to read it now that everything has been bundled.

                                  For lumbar facet joint procedures the terminology is very clear.

                                  L3 medial branch, L4 medial branch, L5 dorsal ramus= 2 joints
                                  2 lumbar facet joint block or two lumbar facet joint RF (L4-L5, L5-S1 facet joints).

                                  L2 medial branch, L3 medial branch, L4 medial branch, L5 dorsal ramus = 3 joints
                                  3 lumbar facet joint block or 3 lumbar facet joint RF (L3-L4, L4-L5, L5-S1 facet joints)

                                  Thank you
                                   

                                  Pacman27

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                                    Below is the Copy of the LCD from First Coast... It clearly states imaging is included.

                                    Contractor Information
                                    Contractor Name

                                    First Coast Service Options, Inc.
                                    Contractor Number

                                    09102
                                    Contractor Type

                                    MAC - Part B
                                    [back to top]
                                    LCD Information
                                    LCD ID Number

                                    L29132
                                    LCD Title

                                    Destruction of Paravertebral Facet Joint Nerve(s)
                                    Contractor's Determination Number

                                    64633
                                    AMA CPT / ADA CDT Copyright Statement

                                    CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
                                    CMS National Coverage Policy

                                    Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860 and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

                                    Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources:


                                    N/A
                                    Primary Geographic Jurisdiction

                                    Florida
                                    Oversight Region

                                    Region IV
                                    Original Determination Effective Date

                                    02/02/2009
                                    Original Determination Ending Date

                                    Revision Effective Date

                                    01/01/2012
                                    Revision Ending Date

                                    Indications and Limitations of Coverage and/or Medical Necessity

                                    A paravertebral facet joint represents the articulation of the posterior elements of one vertebra with its neighboring vertebra. For the purposes of this Local Coverage Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that form it (e.g., C4-5 or L2-3). There are two (2) facet joints at each level, left and right.

                                    Facet joint pain is generally suspected in patients with cervical, thoracic and or lumbar pain that may or may not have a radicular component, when focal tenderness is present over the facet joint, and increased symptoms due to rotation or extension of the spine.

                                    Destruction of a paravertebral facet joint nerve(s) requires the use of fluoroscopic guidance to confirm the proper positioning of the needle or electrode at the level of the involved paravertebral facet joint(s). Destruction of the paravertebral facet joint nerve (s) (median branch) can then be achieved by means of thermal, electrical or radiofrequency (rhizotomy) applications. Facet joint nerve destruction is considered a definitive form of treatment for facet joint pain. Therefore, it would not be expected to see multiple repeat facet joint destruction procedures performed once all of the involved facet joints at that spinal level on either side have been denervated. However, the nerves do have the ability to regenerate. If pain recurs in the same distribution and nature, the procedure may be provided at a maximum of two (2) sessions per year (per 12 months).

                                    Indications

                                    Medicare will consider the destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves to be medically reasonable and necessary as follows:

                                    • The paravertebral facet joint(s) have been identified as the source of the patient's pain by undergoing a diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the pain suggests that the facet joint (s) are the source of the symptoms and appropriate for treatment; and

                                    • The patient failed conservative treatment. Conservative treatment may include local heat, traction, nonsteroidal anti-inflammatory medications and anesthetic and

                                    • The paravertebral facet joint(s) destruction is performed by appropriately trained providers.

                                    The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel."

                                    A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

                                    Limitations

                                    Medicare will consider the destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves not medically reasonable and necessary when:

                                    • Performed without fluoroscopic guidance. A mandatory requirement of paravertebral facet joint (median branch) destruction is the use of fluoroscopic guidance to confirm the proper positioning of the needle electrode. Failure to use fluoroscopic guidance will result in the services receiving a denial; or

                                    • The medical records do not support that the patient experienced temporary or prolonged abolition of the pain after a facet joint nerve block injection; or

                                    • The medical records do not demonstrate that destruction was performed at the median branch of the spinal nerve innervating the facet joint.
                                    [back to top]
                                    Coding Information
                                    Bill Type Codes

                                    Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
                                     
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