RFA billing question

[agolden1]

In the middle of an ongoing discussion with billers with the hospital group I work with. Traditionally, they have done cervical and lumbar radiofrequency ablations unilaterally on separate visits. So, a two level lumbar was getting billed out as 64635 and 64636. Unilateral was billed as $5750 and paid back at $2073 through medicare.

I brought up the idea of doing some bilateral RFAs in order to save patients so running back and forth and to open up the opportunity of doing a repeat sooner than 12 months if the patient so required (for those who get 6-11 months of benefit instead of a year), so did a few cases as 64635 and 64636 with a 50 modifier through medicare. Practice manager approached concerned because when this was sent out, we billed $4581 and were paid $2073, which was the same as a unilateral. For some odd reason, I thought 64635 and 64636 with a 50 modifier were supposed to be reimbursed at 100% one side and 50% the other, but is this wrong? Is my group sending something out wrong?

Thanks!

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[callmeanesthesia]

In the middle of an ongoing discussion with billers with the hospital group I work with. Traditionally, they have done cervical and lumbar radiofrequency ablations unilaterally on separate visits. So, a two level lumbar was getting billed out as 64635 and 64636. Unilateral was billed as $5750 and paid back at $2073 through medicare.

I brought up the idea of doing some bilateral RFAs in order to save patients so running back and forth and to open up the opportunity of doing a repeat sooner than 12 months if the patient so required (for those who get 6-11 months of benefit instead of a year), so did a few cases as 64635 and 64636 with a 50 modifier through medicare. Practice manager approached concerned because when this was sent out, we billed $4581 and were paid $2073, which was the same as a unilateral. For some odd reason, I thought 64635 and 64636 with a 50 modifier were supposed to be reimbursed at 100% one side and 50% the other, but is this wrong? Is my group sending something out wrong?

Thanks!

They are talking about the facility fee. That’s paid based on the base procedure code and doesn’t matter how many levels you do or whether it’s unilateral or bilateral.

None of your concern. Do what’s right for the patient.

 

[agolden1]

They are talking about the facility fee. That’s paid based on the base procedure code and doesn’t matter how many levels you do or whether it’s unilateral or bilateral.

None of your concern. Do what’s right for the patient.

So I tend to agree with doing what’s right, but trying to justify to practice manager as I think they’re trying to exert some downward pressure to stick to unilateral to improve payment to the clinic site. Was hoping I had another leg to stand on financially, and also trying to continue to educate myself.

Thanks though.

 

[Ducttape]

remind them for every time you do just one side, you are not doing some other sort of injection on someone else.


yes the massive payment they get is from facility fee.

better is to do more injections on more people than doing different sided injections on the same people.

 

[BobBarker]

Yes, for many, many years I did unilateral for this very reason. I am sure there were many instances where I had some not get paid due to frequency issues but being on wRVU’s that was ultimately the hospitals responsibility to figure out and they always paid me my units whether they were paid or not.

 

[BoardingDoc]

I was under the impression that recently it was ok to do 2 joints (3 injections) if unilateral but only 1 (2 injections per side) if bilateral, thus giving a reason to do them separately if you wanted to do a BL rfa on 2 joints.

Is this correct? Also, I assume that now there's literally zero reason (other than financial) to split a BL RFA into 2 separate unilateral visits?

 

[DOctorJay]

I was under the impression that recently it was ok to do 2 joints (3 injections) if unilateral but only 1 (2 injections per side) if bilateral, thus giving a reason to do them separately if you wanted to do a BL rfa on 2 joints.

Is this correct? Also, I assume that now there's literally zero reason (other than financial) to split a BL RFA into 2 separate unilateral visits?

You can do 3 needles bilaterally every 6 months or 3 needles unilaterally (but both sides on separate days) every 12 months.


It’s the number of sessions of RFA per year not the number of needles.

 

[BobBarker]

Correct, I just lost payment on one due to too many sessions rolling 12 months by just a few days. Different levels but same cpt’s.