Medial branch coding 64495

[buddababa]

My billing and compliance is saying that this 64495 code can only be billed once (bilateral is okay) but for example if i'm doing L2-S1 (unilaterally or even bilaterally), i can't do 64495x2 units. She attached a CPT2020 doc to show this.

Does this make sense to anyone?
Thoughts?

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[DubVille]

I will bill 93, 94, and 95 if I'm doing 3 joints (4 nerves). I've never done more than 3 on a side before. I also never do anything below L5 dorsal ramus.

I've had our prior auth person screw up (probably my handwriting) and submit for more than 3 joints prompting a denial and prior auth.

 

[Agast]

You cannot treat more than 3 joints, it is billed by number of joints, not number of nerves burnt.

 

[buddababa]

You cannot treat more than 3 joints, it is billed by number of joints, not number of nerves burnt.

Agree. However Medicare allows 4 joints in one session in a 12 month period. So, if that’s the case then, how does one get approved to ablate 4 joints unilaterally (if indicated)?

 

[SSdoc33]

Agree. However Medicare allows 4 joints in one session in a 12 month period. So, if that’s the case then, how does one get approved to ablate 4 joints unilaterally (if indicated)?

depends on your LCD. you will get different answers depending on where you live.

also, you really shouldnt be ablating 4 joints unilaterally all that often. that is a L1, L2, L3, L4 mbb and L5 dorsal ramus block. thats a lot

 

[Ducttape]

the max is 3 joints.

you technically can actually target 3 joints and effectively treat 4. (for example, treat L23, L34 L5S1).

but you are only allowed to bill for 3...

 

[buddababa]

depends on your LCD. you will get different answers depending on where you live.

also, you really shouldnt be ablating 4 joints unilaterally all that often. that is a L1, L2, L3, L4 mbb and L5 dorsal ramus block. thats a lot

Agree, I don't do that, my old partner did and I inherited a lot of his patients that have had this done or he discussed having this done. Thanks for the info!

 

[deleted875186]

Follow up question. Do you bill a 64493, 64494, 64495 if you do a L3, L4 and L5 MBB on one side? Or do you need all 4 nerves to bill for the three total joints?

 

[MD87]

Follow up question. Do you bill a 64493, 64494, 64495 if you do a L3, L4 and L5 MBB on one side? Or do you need all 4 nerves to bill for the three total joints?

64493 and 64494. You could bill 64495 if you also did L2.

 

[clubdeac]

This is like pain billing 101. You guys must be brand new grads, or NPs

 

[buddababa]

This is like pain billing 101. You guys must be brand new grads, or NPs

Agree it seems rudimentary billing, but I’ve had 3 different billing companies in 2 years all saying different things; now add in hospital billing and all becomes a cluster

 

[painfree23]

This is like pain billing 101. You guys must be brand new grads, or NPs

Or chiros

 

[geauxg8rs]

Or chiros

Billing needs daily adjustment for the next 8’weeks with five grand up front

 

[MD87]

If have a similar question that I just ran into. Patient with old L1 fracture. I am blocking to T11, 12, L1. Can I bill both thoracic and lumbar on the same day? Do I just bill 1 and take the hit?

 

[DubVille]

If have a similar question that I just ran into. Patient with old L1 fracture. I am blocking to T11, 12, L1. Can I bill both thoracic and lumbar on the same day? Do I just bill 1 and take the hit?

When I've done this, I just pick one. I guess here you could go either way. 90, 91 or 93, 94. I was told this was the easiest way to get approval and not require prior auth (not sure if it's actually correct).

In that example I'd do lumbar 93, 94 since its T12-L1 and L1-2 joints, so its "more" lumbar.

 

[Ducttape]

i like to think this forum is for asking questions, even ones rehashed in the past.

 

[MD87]

When I've done this, I just pick one. I guess here you could go either way. 90, 91 or 93, 94. I was told this was the easiest way to get approval and not require prior auth (not sure if it's actually correct).

In that example I'd do lumbar 93, 94 since its T12-L1 and L1-2 joints, so its "more" lumbar.

I think this makes sense. But, playing devil’s advocate, if you look at it based on the nerve branches, not the actual facets, it’s more thoracic. I guess though, if I would bill it as just lumbar, I would be getting paid less, and so it would be less likely to get me into trouble.

 

[DubVille]

I think this makes sense. But, playing devil’s advocate, if you look at it based on the nerve branches, not the actual facets, it’s more thoracic. I guess though, if I would bill it as just lumbar, I would be getting paid less, and so it would be less likely to get me into trouble.

Sure, but you are treating the joint, not the "nerves."

I dont actually know the correct answer, but I have ran into this a few times and never had trouble billing this way.

 

[Dansk2011]

You'd be suprised how many people either don't know how to bill these procedures properly or chose not to. I think it's one of the most frequent "mistakes" found on procedural audits in pain medicine. I know someone who knowingly bills per injection or rf and not per joint actually treated despite being told otherwise.