Sacral rf billing

[smarterchild]

Hi all,
I recently started billing sacral rf procedures with cpt code 64625 and diagnosis codes m46.1 and m13.88 for sacroiliac joint pain. I remember reading about this change on another thread. however, bcbs is denying the claim saying this is an “unproven procedure” and the cpt code doesn’t match with the diagnosis code

is this the same diagnosis/Cpt combo you all are using? And, if so, are you running into the same issue? Thanks

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[swamprat]

Hi all,
I recently started billing sacral rf procedures with cpt code 64625 and diagnosis codes m46.1 and m13.88 for sacroiliac joint pain. I remember reading about this change on another thread. however, bcbs is denying the claim saying this is an “unproven procedure” and the cpt code doesn’t match with the diagnosis code

is this the same diagnosis/Cpt combo you all are using? And, if so, are you running into the same issue? Thanks

I bill it as a lumbar RFA. Levels L4, L5, S1, S2. Cigna still gave me a problem with this so I just billed the typical lumbar RF and did the SI lateral branches instead

 

[Ronin1]

Hi all,
I recently started billing sacral rf procedures with cpt code 64625 and diagnosis codes m46.1 and m13.88 for sacroiliac joint pain. I remember reading about this change on another thread. however, bcbs is denying the claim saying this is an “unproven procedure” and the cpt code doesn’t match with the diagnosis code

is this the same diagnosis/Cpt combo you all are using? And, if so, are you running into the same issue? Thanks

Blue cross typically does not cover SI RFA

 

[bedrock]

Blue cross typically does not cover SI RFA

Agree they haven’t covered SIJ RFA in the past, but now that it has a dedicated Medicare code, I would think they should now cover it.

 

[smarterchild]

Thanks all! They covered the diagnostic but not the rf. Doesn’t make much sense

 

[10KHertz]

There are many types of BCBS: exchange, commercial , local, Mediblue, MC, etc.
All are somewhat different with benefits. Local BCBS you can do it . Exchange no way ...

 

[Needlejockeys]

There are many types of BCBS: exchange, commercial , local, Mediblue, MC, etc.
All are somewhat different with benefits. Local BCBS you can do it . Exchange no way ...

recently had denials from UHC as well :/

 

[Agast]

Diagnostics are typically covered, it’s the ablation for therapeutic benefit that is considered experimental.

 

[Ferrismonk]

I bill it as a lumbar RFA. Levels L4, L5, S1, S2. Cigna still gave me a problem with this so I just billed the typical lumbar RF and did the SI lateral branches instead

So, fraud?

 

[Ferrismonk]

SI RFA was billed as peripheral nerve RFA last year which was often approved based on the codes used. Now that there is a specific code, many insurances won't cover it. Sucks, but that's how it works.

 

[drusso]

SI RFA was billed as peripheral nerve RFA last year which was often approved based on the codes used. Now that there is a specific code, many insurances won't cover it. Sucks, but that's how it works.

What's the code?

 

[SommeRiver]

I've quit this procedure.

 

[Ferrismonk]

What's the code?

Last year we were billing 64640x4, 77003. This year 64625.

 

[TIVAndy]

having same issues with bcbs on genicular rfa. used to go through with 64640

 

[FF430]

I've quit this procedure.

what r u offering for SIJ pain then? joint Injection are only lasting a few weeks.

 

[SommeRiver]

what r u offering for SIJ pain then? joint Injection are only lasting a few weeks.

I do SIJ RFA maybe one every other quarter. I don't find them helpful, at least not reliably. I do joint injections and PT. I'm offering PRP to those who want to pay for it.

How do you know the SIJ is the pain generator? Many things hurt there, and those same things are reliably painful with the same provocative maneuvers...

I can't tell you how many times I've sent a pt to PT and had them come back and tell me their therapist told them it is their SIJ AND their piriformis.

 

[geauxg8rs]

I do SIJ RFA maybe one every other quarter. I don't find them helpful, at least not reliably. I do joint injections and PT. I'm offering PRP to those who want to pay for it.

How do you know the SIJ is the pain generator? Many things hurt there, and those same things are reliably painful with the same provocative maneuvers...

I can't tell you how many times I've sent a pt to PT and had them come back and tell me their therapist told them it is their SIJ AND their piriformis.

. Agreed. Any pain that is radicular that starts anywhere in the vicinity of the SI joint is piriformis syndrome. Anything non radicular is SI joint. Uncanny

 

[clubdeac]

I do SIJ RFA maybe one every other quarter. I don't find them helpful, at least not reliably. I do joint injections and PT. I'm offering PRP to those who want to pay for it.

How do you know the SIJ is the pain generator? Many things hurt there, and those same things are reliably painful with the same provocative maneuvers...

I can't tell you how many times I've sent a pt to PT and had them come back and tell me their therapist told them it is their SIJ AND their piriformis.

Hmmpf...you're probably not doing it right then. How do you know it's the generator? You inject it and see how they do. Or you block the lateral branches and see how they do. Sure there's anterior and posterior innervation making it a difficult joint to treat but there's no question it's a legitimate pain generator and may respond well to posterior lateral branch ablation.

 

[SommeRiver]

Hmmpf...you're probably not doing it right then. How do you know it's the generator? You inject it and see how they do. Or you block the lateral branches and see how they do. Sure there's anterior and posterior innervation making it a difficult joint to treat but there's no question it's a legitimate pain generator and may respond well to posterior lateral branch ablation.

I know it is a legitimate pain site, but I rarely get what I would consider worthwhile relief from that ablation.

I do 4 needles and a total of 7 sites. I wish I could remember the last pt I did this on and I'd post pics for criticism and troubleshooting. Next time a pt circles back through I'll post those.

 

[iwumd07]

I've already had 3 denials from BCBS in the last few months for SI RFA. These were to be repeat procedures in patients that had about 80% relief, and all of them had relief lasting about 6-9 months. Did P2P and was denied each time. Each time, I'm told it's 'not their policy'. Again, when trying to discuss data and research with the 'doctor' on the phone, I get the response of "we don't base our policies on data". Apparently, they just want all their customers to go for the SI joint fusion.

Also, how are people getting approved for CornerLoc and PainTeq procedures for SI joint "fusions"?!?! One of my friends in Florida is doing like 3-5 a week! I also don't understand how patients get any relief from these procedures, as the joint isn't 'unstable', and a bone graft doesn't make any logical sense to me. Can anyone explain the science?

 

[Espn123]

I've already had 3 denials from BCBS in the last few months for SI RFA. These were to be repeat procedures in patients that had about 80% relief, and all of them had relief lasting about 6-9 months. Did P2P and was denied each time. Each time, I'm told it's 'not their policy'. Again, when trying to discuss data and research with the 'doctor' on the phone, I get the response of "we don't base our policies on data". Apparently, they just want all their customers to go for the SI joint fusion.

Also, how are people getting approved for CornerLoc and PainTeq procedures for SI joint "fusions"?!?! One of my friends in Florida is doing like 3-5 a week! I also don't understand how patients get any relief from these procedures, as the joint isn't 'unstable', and a bone graft doesn't make any logical sense to me. Can anyone explain the science?

“Science” = a relatively immobile joint becomes slightly more mobile leads to painful sacroiliac joint - bone graft fixation reduces the hypermobility leading to pain relief. I’ll look forward to seeing the studies play out...

 

[clubdeac]

Was just told by our biller that 64625 is worth 3.39 wRVUs. Wow, just a little more than a two level TFESI (1.9 + 1).

Terrible...

 

[bedrock]

Was just told by our biller that 64625 is worth 3.39 wRVUs. Wow, just a little more than a two level TFESI (1.9 + 1).

Terrible...

All ablations other than facet ablations pay terribly and the new codes make it so you can't even charge the old codes which weren't much anyway.

Now I just charge cash now for SIJ, genicular ablations, (unless on medicare where it is actually still a covered benefit).

 

[Multimodal]

I had a conversation with a Kaiser neurologst during a P2P for a 100 year old patient. same as above, they covered the genicular block but not the RFA and their rationale was that it is experimental but if I could find an LCD showing that medicare covers it, then they would too. I tried to explain how the code changed this year and medicare does not yet have an LCD for this new code in particular but that didn't win him over. I essentially played the "do you really want to do this to a 100 year old patient" card.....and that worked but they went out of their way to say that this does not represent a change in their policy just an exemption.

 

[drusso]

All ablations other than facet ablations pay terribly and the new codes make it so you can't even charge the old codes which weren't much anyway.

Now I just charge cash now for SIJ, genicular ablations, (unless on medicare where it is actually still a covered benefit).

Cash-based practices are the future of pain. Pain has become cosmetic.