RFA - procedural/coding question

[Drd105]

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Let’s say I knew someone who billed 64635 and 64636 and only used two needles to perform that injection (needles placed at L4MB and L5DR).
Is there a textbook or article someone could direct me to that outlines how that procedure should actually require 3 needles?
The cms guidelines for RFA speak on billing levels, but not needles required to treat said levels.
I looked in my rothman text and found nothing, and don’t see anything on google.

 

[lobelsteve]

Let’s say I knew someone who billed 64635 and 64636 and only used two needles to perform that injection (needles placed at L4MB and L5DR).
Is there a textbook or article someone could direct me to that outlines how that procedure should actually require 3 needles?
The cms guidelines for RFA speak on billing levels, but not needles required to treat said levels.
I looked in my rothman text and found nothing, and don’t see anything on google.

Straight up fraud.
2 medial branches run from each joint. 3 nerves for 2 levels. Can use 1, 2, or 3 needles to accomplish this.
For example, L3, L4, L5 branches RF will take out the L4-5 and L5-S1 Z joints.

 

[Drd105]

Straight up fraud.
2 medial branches run from each joint. 3 nerves for 2 levels. Can use 1, 2, or 3 needles to accomplish this.
For example, L3, L4, L5 branches RF will take out the L4-5 and L5-S1 Z joints.

I feel like if I approach the person I need some sort of reference- other than here’s the deal, this is fraud, not sure why you didn’t learn this in training…Etc

It’s kind of interesting that the CMS guidelines do not outline needles required. This person can’t be the only one who thinks this is okay.

 

[lobelsteve]

I feel like if I approach the person I need some sort of reference- other than here’s the deal, this is fraud, not sure why you didn’t learn this in training…Etc

It’s kind of interesting that the CMS guidelines do not outline needles required. This person can’t be the only one who thinks this is okay.

Not needles. Levels. A needle is a tool. You can do 10 levels with a single needle, but it will take all day.

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Why are you approaching the person anyways?

 

[callmeanesthesia]

Hypothetically, if you report someone like that for fraud to CMS, do you get a whistleblower % take on what they recover?

 

[Drd105]

Hypothetically, if you report someone like that for fraud to CMS, do you get a whistleblower % take on what they recover?

Lolol- not looking for cash…

Steve-
This is very odd and confusing I know- but i am now starting to share follow ups for this person’s injections and I want to be clear that I am documenting the correct way.
For example, I was planning a repeat RFA for the other provider to perform.
I reviewed the procedure note stating that last year “L3-S1 (this is improper, I know) RFA performed October 2021”
When I know that was ACTUALLY performed was an L4-5 RFA (treating L5-S1 only), I don’t want to document that something else was done that wasn’t, for fear of incriminating myself in a potential audit, does that make sense? The patient actually had an insurance carrier that sent a notification out recently that they would be doing random chart audits, btw.

Also, is it not my duty to attempt to educate the person, so as I am not a co-conspirator in the fraud?

I’m really not sure.

 

[Analgesia108]

U cld request and review their op notes to be sure what was done before repeating it or doing what you feel is appropriate

 

[Drd105]

U cld request and review their op notes to be sure what was done before repeating it or doing what you feel is appropriate

I’m sorry I worded this in a confusing manner I think. This is my partner I’m referring to.

 

[MD87]

What about if they are fused L3-4. And you want to block L4-5 and 5-1. In this case it would be 2 needles, 1 at L4 MB and 1 at L5 DR. How would you guys bill this? 1 level or 2?

 

[Ferrismonk]

What about if they are fused L3-4. And you want to block L4-5 and 5-1. In this case it would be 2 needles, 1 at L4 MB and 1 at L5 DR. How would you guys bill this? 1 level or 2?

You can do L4 MB (which is at L5) and L5 DR at ala. This would be a 1-joint RF. You cannot completely block the L4/L5 joint (MBs L3 and L4), so you don't bill it.

 

[Ferrismonk]

Hypothetically, if you report someone like that for fraud to CMS, do you get a whistleblower % take on what they recover?

The answer is yes, although it's more complicated than just reporting someone. You need to have cases as proof, not just rumors of bad behavior.

 

[callmeanesthesia]

What about if they are fused L3-4. And you want to block L4-5 and 5-1. In this case it would be 2 needles, 1 at L4 MB and 1 at L5 DR. How would you guys bill this? 1 level or 2?

That’s only an L5-S1 block/ablation. Personally I’d also try to put a needle at L4 vertebral level as well, assuming the geometry of the fusion allows.

 

[MD87]

You can do L4 MB (which is at L5) and L5 DR at ala. This would be a 1-joint RF. You cannot completely block the L4/L5 joint (MBs L3 and L4), so you don't bill it.

I don’t disagree with this. However, with that line of reasoning, if someone is fused at L4-5 and you do L5 DR block you wouldn’t be able to bill for it.

 

[Ferrismonk]

I don’t disagree with this. However, with that line of reasoning, if someone is fused at L4-5 and you do L5 DR block you wouldn’t be able to bill for it.

If they are fused L4/L5, a L5 DR block by itself is not billable. You could do intra-articular L5/S1 if insurance allows. SIJ RFA is also a possibility if insurance allows, which would cover the L5 DR.

 

[Orin]

If they are fused L4/L5, a L5 DR block by itself is not billable. You could do intra-articular L5/S1 if insurance allows. SIJ RFA is also a possibility if insurance allows, which would cover the L5 DR.

I don’t disagree with this. However, with that line of reasoning, if someone is fused at L4-5 and you do L5 DR block you wouldn’t be able to bill for it.

I suppose one can technically bill it with a reduced services modifier (-52 vs -53) if you don't like getting paid, but most people would just treat/bill for the adjacent joint. My understanding though was that insurance denied fused levels now.

 

[deleted875186]

Lolol- not looking for cash…

Steve-
This is very odd and confusing I know- but i am now starting to share follow ups for this person’s injections and I want to be clear that I am documenting the correct way.
For example, I was planning a repeat RFA for the other provider to perform.
I reviewed the procedure note stating that last year “L3-S1 (this is improper, I know) RFA performed October 2021”
When I know that was ACTUALLY performed was an L4-5 RFA (treating L5-S1 only), I don’t want to document that something else was done that wasn’t, for fear of incriminating myself in a potential audit, does that make sense? The patient actually had an insurance carrier that sent a notification out recently that they would be doing random chart audits, btw.

Also, is it not my duty to attempt to educate the person, so as I am not a co-conspirator in the fraud?

I’m really not sure.

Honestly, I would probably simply not look at fluoro images, and write in your note “per Dr so and so records, a L4-5, L5-S1 RFA was performed with pain relief for blah blah, patient wants to repeat”.

If you had to perform a procedure for their patients, I would simply perform the requested procedure with the appropriate amount of levels and save images.

If you want to address the issue, I beleive the Medicare LCD on facet does say that two median nerves are required to block a complete joint level, would have to look it up.

 

[Drd105]

Honestly, I would probably simply not look at fluoro images, and write in your note “per Dr so and so records, a L4-5, L5-S1 RFA was performed with pain relief for blah blah, patient wants to repeat”.

If you had to perform a procedure for their patients, I would simply perform the requested procedure with the appropriate amount of levels and save images.

If you want to address the issue, I beleive the Medicare LCD on facet does say that two median nerves are required to block a complete joint level, would have to look it up.

Thanks, you’re right….I think the best course of action is to stick to the facts and quote his notes in my note, as you demonstrated.

You are correct- I found this on review of the essay after the “definitions” section: “Each facet has a dual nerve supply. One exception is at the C2–C3 zygapophysial joint, which has a singular nerve supply from the third occipital nerve (the superficial medial branch of C3 dorsal ramus).”

Thanks!

 

[callmeanesthesia]

Let’s say I knew someone who billed 64635 and 64636 and only used two needles to perform that injection (needles placed at L4MB and L5DR).
Is there a textbook or article someone could direct me to that outlines how that procedure should actually require 3 needles?
The cms guidelines for RFA speak on billing levels, but not needles required to treat said levels.
I looked in my rothman text and found nothing, and don’t see anything on google.

Depends on personality. Went through the same thing with my partner. I printed out the Medicare LCD and highlighted the sections that specify that you bill per facet level. Took a while to get through to him but I did eventually get him on board. He’s pretty easy-going in general but insisted for a while that he really felt he should be getting paid per needle, and insurance companies were ripping us off trying to pay per joint (I mean, he’s not wrong, but Medicare sets the rules and we have to play by them).

 

[bedrock]

If they are fused L4/L5, a L5 DR block by itself is not billable. You could do intra-articular L5/S1 if insurance allows. SIJ RFA is also a possibility if insurance allows, which would cover the L5 DR.

of course it is billable. Are you supposed to 1- do it for free? 2- tell the patient to suck it up because it is not billable ?

I've billed for that exact procedure 50 times and always been paid. No reason for us to not to bill it because there is hardware blocking part of the nerve supply.

 

[Ducttape]

I don’t disagree with this. However, with that line of reasoning, if someone is fused at L4-5 and you do L5 DR block you wouldn’t be able to bill for it.

wait, what?

L5 DR innervates L5S1 facet joint. what does that have to do with L45? or are you saying you cant treat L5S1 because there is no L4MB?

i dont think CMS's point of not being able to bill for a fused segment is because the median branches are not accessible - it is because that segment is fused so there is no movement of those facets.

so as far as L5S1 facet joint, if the only innervation going to that joint is L5DR, then a single lesion of L5DR should be covered for a single joint RFA...

 

[Drd105]

wait, what?

L5 DR innervates L5S1 facet joint. what does that have to do with L45? or are you saying you cant treat L5S1 because there is no L4MB?

i dont think CMS's point of not being able to bill for a fused segment is because the median branches are not accessible - it is because that segment is fused so there is no movement of those facets.

so as far as L5S1 facet joint, if the only innervation going to that joint is L5DR, then a single lesion of L5DR should be covered for a single joint RFA...

Agree, this is what I have done.

 

[Drd105]

Depends on personality. Went through the same thing with my partner. I printed out the Medicare LCD and highlighted the sections that specify that you bill per facet level. Took a while to get through to him but I did eventually get him on board. He’s pretty easy-going in general but insisted for a while that he really felt he should be getting paid per needle, and insurance companies were ripping us off trying to pay per joint (I mean, he’s not wrong, but Medicare sets the rules and we have to play by them).

Thank you…glad to hear I’m not the only one.

 

[DODOCSS]

so elementary

 

[MitchLevi]

I do L5 DPR underneath an L4-5 fusion all the time. Yes, of course I bill for it!

In a broader point of discussion though, billing for a procedure and subsequent payment does not mean you're doing something correctly.

RAC audits can take money from you for things you did with permission.