Medicare dropping 64624 (genicular RFA)?

[agolden1]

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Billers at my office telling me we’re no longer getting reimbursed by Medicare for genicular RFA. They were one of our only payers who allowed for it. I hadn’t seen any chatter about this, and there’s not really a LCD to speak to this. Anyone experiencing anything different or a workaround?

Thanks

 

[runfastnow]

Anecdotally have had the same experience. This month we moved all genicular RFA to cash pay.

 

[GorillaPanic]

Have you been having trouble getting the diagnostic blocks covered too? Or just RFA?

 

[agolden1]

Diagnostic getting covered. Just RFA.

 

[swamprat]

Interesting - well I semi like that because reimbursement sucked and it was a pain in the ass to do despite some patients getting great relief.

 

[callmeanesthesia]

I’ve emailed my billers and asked for a report on the past 6 months to see if I’m having any issues.

 

[Multimodal]

I'm in WA state, we have been getting reimbursed so far. last one I got paid for was end of May. the other claims are likely still processing. hope its just a hiccup in the claims pipeline for you guys

 

[geauxg8rs]

Diagnostic getting covered. Just RFA.

How can they justify paying for the test but not the treatment? I am sure if we ask cms they will just axe the diagnostic blocks then too.

 

[bedrock]

Anecdotally have had the same experience. This month we moved all genicular RFA to cash pay.

Billers at my office telling me we’re no longer getting reimbursed by Medicare for genicular RFA. They were one of our only payers who allowed for it. I hadn’t seen any chatter about this, and there’s not really a LCD to speak to this. Anyone experiencing anything different or a workaround?

Thanks

Just to be clear, you guys are saying that regular Medicare isn’t paying for genicular RFA? (Not Medicare advantage?)

 

[BobBarker]

It is contractor dependent I am sure. Have t heard anything about novitas.

 

[Agast]

It is contractor dependent I am sure. Have t heard anything about novitas.

I feel like Novitas is the most chill of the Medicare regions but I don’t understand why people across the country can have the exact same insurance but different access to services

 

[soxman]

Is it possible to use CPT 64640?

 

[BobBarker]

I feel like Novitas is the most chill of the Medicare regions but I don’t understand why people across the country can have the exact same insurance but different access to services

Yes, agreed. Novitas very chill, just like the people they represent.

 

[agolden1]

On insurance face sheets, our office says they just say "Medicare or Medicare B." Nothing more than this. A few private insurers are covering locally still.

I am less certain of using 64640. We use it for doing genicular steroid injections for folks with severe pain who cannot get approval for RFA, but I'm not sure the revenue would cover the cost of RFA.

Not the biggest fan of doing these procedures, but we have a handful of folks this really seems to help with, so I do hate to see it go.

 

[MitchLevi]

Only blocks are covered for me, so I don’t do them. I offer genicular RFA for $800 and that’s it.

Probably going to do a few SPRINT cases soon.

 

[SpineandWine]

Only blocks are covered for me, so I don’t do them. I offer genicular RFA for $800 and that’s it.

Probably going to do a few SPRINT cases soon.

Is that for genicular mononeuropathy?
I have n=2, both moderately happy (they keep their device on, don’t want it removed and helps them greater than 50%)

 

[MitchLevi]

Is that for genicular mononeuropathy?
I have n=2, both moderately happy (they keep their device on, don’t want it removed and helps them greater than 50%)

I guess yeah, but I do not believe post TKA pain is neuropathic personally, or at least I don’t feel comfortable naming the nerve. I just feel if you have a TKA and you’re miserable there has got to be something neuropathic there, and all things considered, PNS is safe for the most part.

I do worry about TKA pts and infxn risk though.

 

[Orin]

Haven't heard about it. I use the peripheral nerve block LCDs to get Medicare and most Medicare Advantage folks to authorize the genicular blocks and RFAs.

L33933 (LCD - Peripheral Nerve Blocks (L33933)) and L36850 (LCD - Peripheral Nerve Blocks (L36850))

The argument is this is a diagnostic block to verify the pain is coming from the knee joint and not the hip/back/etc.

From the LCDS:
L33933: "When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear. "
L36850: "When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear but this is only for diagnostic purposes and not long term treatment."

Both then say "In some cases, neurolysis may be appropriate to provide lasting relief."

The ICD10 though should be pain
M25.561 Pain in right knee
M25.562 Pain in left knee
M25.569 Pain in unspecified knee

It doesn't work every time as now some of the MedAdv plans fall back on commercial guidelines

 

[agolden1]

Haven't heard about it. I use the peripheral nerve block LCDs to get Medicare and most Medicare Advantage folks to authorize the genicular blocks and RFAs.

L33933 (LCD - Peripheral Nerve Blocks (L33933)) and L36850 (LCD - Peripheral Nerve Blocks (L36850))

The argument is this is a diagnostic block to verify the pain is coming from the knee joint and not the hip/back/etc.

From the LCDS:
L33933: "When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear. "
L36850: "When selective peripheral nerve blockade is used diagnostically in those cases in which the clinical picture is unclear but this is only for diagnostic purposes and not long term treatment."

Both then say "In some cases, neurolysis may be appropriate to provide lasting relief."

The ICD10 though should be pain
M25.561 Pain in right knee
M25.562 Pain in left knee
M25.569 Pain in unspecified knee

It doesn't work every time as now some of the MedAdv plans fall back on commercial guidelines

So essentially you’re sending out as 64640 instead of 64624 for ablation if sending out as other peripheral nerve?

 

[callmeanesthesia]

My billers said I haven’t had any denials of payment from Medicare for genicular ablations. I don’t do a ton of them but at least one in the past few months was paid.

 

[Orin]

So essentially you’re sending out as 64640 instead of 64624 for ablation if sending out as other peripheral nerve?

No, the LCDs explicitly cover 64624 in addition to 64640. I reserve 64640 for other non-named ablations like the shoulder/hip targets.

Facet joints, genicular, SI lateral branches, trigeminals, BVNA, and some of the sympathetic chains have defined codes for thermal RFA but everything else is fair game under 64640. So if you want to burn some middle cluneals, have at it.

 

[Ducttape]

you should confirm you are getting paid for 64640.

some insurances "cover" but then do not pay for those procedures.

particularly SI branches, or geniculars. because they are not generic nerve RFA.

 

[Blackmateria]

Only blocks are covered for me, so I don’t do them. I offer genicular RFA for $800 and that’s it.

Probably going to do a few SPRINT cases soon.

Where are you planning on putting the leads? Also how many?

 

[PMROralBoards]

Where are you planning on putting the leads? Also how many?

Saphenous and lateral genicular is the normal placement. I just did one on Monday.

 

[Ferrismonk]

I haven't heard anything about Genicular not being covered. It should continue to be covered since there is not an LCD for it. I'll ask my billers too.

For those who say use the peripheral nerve code instead, you should know that can be considered fraud since there is specific code for this procedure.

 

[Drd105]

you should confirm you are getting paid for 64640.

some insurances "cover" but then do not pay for those procedures.

particularly SI branches, or geniculars. because they are not generic nerve RFA.

Yes they say “no auth required” buuuuuut that doesn’t mean we will pay you. You just don’t need auth. For the lack of payment. Just go for it!

 

[powermd]

The allowable on this is $382.84 in Maine. They can *have* this procedure. I do it as a courtesy to referring docs only and see it as a loss leader. Meanwhile the vet wants $300 to xray my cat.

 

[Taus]

The allowable on this is $382.84 in Maine. They can *have* this procedure. I do it as a courtesy to referring docs only and see it as a loss leader. Meanwhile the vet wants $300 to xray my cat.

I started saying no to this procedure years ago… In addition to the minimal reimbursement… My results were just fair and inviting failed knees is too much when you already see failed backs

 

[paindoc007]

I started saying no to this procedure years ago… In addition to the minimal reimbursement… My results were just fair and inviting failed knees is too much when you already see failed backs

This. I quickly learned there’s nothing worse than being a dumping ground for orthopedics after failed TKA. Literally the worst patients. Not desperate for business, so I said no thanks to it years ago.

 

[callmeanesthesia]

I just tell them it’s the only thing I can do for them, and give it a go. Only takes 10-15 minutes.

 

[powermd]

I just tell them it’s the only thing I can do for them, and give it a go. Only takes 10-15 minutes.

What's your lesion protocol? I do three 60s lesions at 80C at each site fanning the needle around the target zones. I've found ultrasound is a much kinder way to place the needles and do local, although I rough in with fluoro. Takes me too long for the crappy reimbursement, but I do get good results.

 

[callmeanesthesia]

Fluoro guided, AP approach. I used to get a lot more fancy. Now I numb skin, put the RF needles in a few inches, and start numbing a tract down to the targets, then switch to lateral and put the tips about 2/3 of the way across the femur, injecting local as I go. Then I add a little more local, motor test, and burn for 90 seconds 80 degrees, pull them back a cm, and burn again.

 

[Agast]

Fluoro guided, AP approach. I used to get a lot more fancy. Now I numb skin, put the RF needles in a few inches, and start numbing a tract down to the targets, then switch to lateral and put the tips about 2/3 of the way across the femur, injecting local as I go. Then I add a little more local, motor test, and burn for 90 seconds 80 degrees, pull them back a cm, and burn again.

What are you looking for on the motor testing?

 

[BobBarker]

I don’t have any problem with motor testing geniculars. I am not really looking for anything but it doesn’t throw the MA off her routine and gives a little more time for the local to setup.

I didn’t motor test at the hospital. We had moderate sedation to help the local along. We also had different staff that could handle changes in protocol better.

 

[mille125]

Agree with what others have said. I have good results with some having 2-3 years of relief but reimbursement is not great as has been said.

I advertise to the orthos for total knees or other knee failures because in addition to geniculars, I have laser, shockwave, ozone, and scrambler. I know you guys think that is garbage but about 8-9 out of 10 of these patients end up leaving my office much better than they entered especially if they have CRPS.

 

[nvrsumr]

I had my first crps patient in a couple years today.

 

[mille125]

I had my first crps patient in a couple years today.

Its hard but they now seek me...

 

[drusso]

Do this instead:

Comparison of the efficacy of genicular nerve phenol neurolysis and radiofrequency ablation for pain management in patients with knee osteoarthritis - PMC

Genicular nerve neurolysis with phenol and radiofrequency ablation (RFA) are two interventional techniques for treating chronic refractory knee osteoarthritis (KOA) pain. This study aimed to compare the efficacy and adverse effects of both ...

pmc.ncbi.nlm.nih.gov

https://www.sciencedirect.com/science/article/pii/S2772594423000080

Chemical Ablation of Genicular Nerve with Phenol for Pain Relief in Patients with Knee Osteoarthritis: A Prospective Study - PubMed

Chemical neurolysis of genicular nerves with phenol provided efficacious analgesia and functional improvement for at least 6 months in most patients with a low incidence of adverse effects.

pubmed.ncbi.nlm.nih.gov

 

[GatorCHOMPions]

Do this instead:

Comparison of the efficacy of genicular nerve phenol neurolysis and radiofrequency ablation for pain management in patients with knee osteoarthritis - PMC

Genicular nerve neurolysis with phenol and radiofrequency ablation (RFA) are two interventional techniques for treating chronic refractory knee osteoarthritis (KOA) pain. This study aimed to compare the efficacy and adverse effects of both ...

pmc.ncbi.nlm.nih.gov

https://www.sciencedirect.com/science/article/pii/S2772594423000080

Chemical Ablation of Genicular Nerve with Phenol for Pain Relief in Patients with Knee Osteoarthritis: A Prospective Study - PubMed

Chemical neurolysis of genicular nerves with phenol provided efficacious analgesia and functional improvement for at least 6 months in most patients with a low incidence of adverse effects.

pubmed.ncbi.nlm.nih.gov

The first study you cited has been retracted...

 

[Ducttape]

um...

i believe the cpt code for chemical neurolysis is the same as radiofrequency neurolysis ie 64624. so it would not be covered under Medicare.

 

[plasma.]

Agree with what others have said. I have good results with some having 2-3 years of relief but reimbursement is not great as has been said.

I advertise to the orthos for total knees or other knee failures because in addition to geniculars, I have laser, shockwave, ozone, and scrambler. I know you guys think that is garbage but about 8-9 out of 10 of these patients end up leaving my office much better than they entered especially if they have CRPS.

Can you tell us more about your treatment options for CRPS? By the time they see me they've already tired all the meds and desensitization / mirror therapy etc. I offer sympathetic blocks if the limb is cold, plexus / nerve blocks if not cold, then Ketamine infusions. Ketamine seems to work reasonably well but most patients only get 4 - 6 weeks relief. We also try to get them a Pamidronate infusion. Would love to know more about your tips/tricks!

 

[bedrock]

Can you tell us more about your treatment options for CRPS? By the time they see me they've already tired all the meds and desensitization / mirror therapy etc. I offer sympathetic blocks if the limb is cold, plexus / nerve blocks if not cold, then Ketamine infusions. Ketamine seems to work reasonably well but most patients only get 4 - 6 weeks relief. We also try to get them a Pamidronate infusion. Would love to know more about your tips/tricks!

Sounds like those patients need SCS.

 

[mille125]

Can you tell us more about your treatment options for CRPS? By the time they see me they've already tired all the meds and desensitization / mirror therapy etc. I offer sympathetic blocks if the limb is cold, plexus / nerve blocks if not cold, then Ketamine infusions. Ketamine seems to work reasonably well but most patients only get 4 - 6 weeks relief. We also try to get them a Pamidronate infusion. Would love to know more about your tips/tricks!

CRPS is really tough especially in those multi-extremity cases. SCS is definitely a good option if some of the things mentioned above fail. DRG stim may be better than regular SCS.

A newer less invasive technique is scrambler therapy. As someone who does both scrambler and SCS, I will tell you that the efficacy rate is similar and around 65% for both treatments. I have a few patient who have had long term relief with SCS. I also have a few patients who get habituation and are explanted and a few who have had complications. Scrambler is newer and I have only been doing it for less than a year so I don't have long term patient data and it hasn't really been studied long-term but it is promising and it is minimally invasive without side effect or complication.

These are probably the best options. Either way it is a tough condition to treat. The only thing that I have run into that is harder to treat is arachnoiditis. I personally have found nothing that works consistently for that condition. If anyone on the forum his some pearls for treating arachnoiditis, I would love to hear it.

 

[Ducttape]

i dont do DRG but one of my colleagues did. not encouraging results (or stim overall). in fact, the major proceduralist group in this area has stopped doing DRG altogether.

 

[mille125]

i dont do DRG but one of my colleagues did. not encouraging results (or stim overall). in fact, the major proceduralist group in this area has stopped doing DRG altogether.

I dont do it either but it is at least reported to work...

 

[lobelsteve]

I dont do it either but it is at least reported to work...

I do it and it can work. But not magical or better than conventional SCS. And the wires are fragile and finicky. It is better for the doc (fun/challenge) than the patient. Also more frustrating.

 

[Gnarvin]

I do it and it can work. But not magical or better than conventional SCS. And the wires are fragile and finicky. It is better for the doc (fun/challenge) than the patient. Also more frustrating.

I agree. I used to be part of a practice where the other physicians did a lot of DRG and it seemed to be a huge headache. Lead fracture and migration were very common. Lots of revisions were required. I choose to avoid doing DRG for the most part due to the high incidence of lead fracture and/or migration.

 

[drusso]

I agree. I used to be part of a practice where the other physicians did a lot of DRG and it seemed to be a huge headache. Lead fracture and migration were very common. Lots of revisions were required. I choose to avoid doing DRG for the most part due to the high incidence of lead fracture and/or migration.

One man's headache is another man's facility fee.

 

[Dr. Ice]

Back to the original thread..how have people been doing with pns for post tka pain. I believe it’s still covered by Medicare

 

[Dr. Ice]

I have 2 handfuls of patients dependent on genicular rfa that benefit every 18 months.
They are mostly straight Medicare. Have any of you had good results with PNS in these patients?