Download Neurolysis Lumbar Facets Coding Issue

8/04/09
Dear Dr. Corcoran
Thank you for persevering on this clarification issue. I will try my best to reconstruct the
history of this coding issue.
64622 Neurolysis Lumbar Facet, CPT, p 281, ( Destruction by neurolytic agent
paravertebral facet joint nerve; lumbar or sacral, single level) – This is the code we
typically use for radiofrequency of the facet joint. Even thought the CPT descriptor
states lumbar or sacral, there is confusion about ablation of the sacrum. The literature
supports that the L5 facet is innervated by the S1 lateral branch up into the L5 facet. But
in the past coders and compliance officers have questioned this. Therefore we would like
clarification that we can ablate the sacral lateral branch for denervation of L5 in the LCD.
Concomitant to this issue is that we ablate the sacrum by radiofrequency of the S1, S2, S3
and S4 lateral branches. This has been controversial as to whether these are peripheral
nerves, but they are not, they are lateral branches of the dorsal ramus of the S1, S2, S3,
S4 foramen to the SI joint, therefore code 64640 should have nothing to do with it.
When we provide a SI joint injection and it does not last denervation would be the next
step.
Of course I fear that if the LCD does not spell this our clearly it might be an area for
RAC interpretation, which we do not want. If the LCD spells this out more clearly there
will be no question.
Below is the last draft LCD that I received from Juanita regarding 64622. I have
highlighted in yellow the areas that I would recommend for clarification and finalization
of this confusion.
Indications and Limitations of Coverage and/or Medical Necessity
A paravertebral facet joint represents the articulation of the posterior elements of one
vertebra with its neighboring vertebra. For the purposes of this Local Coverage
Determination (LCD), the facet joint is noted at a specific level, by the vertebrae that
form it (e.g., C4-5 or L2-3). There are two (2) facet joints at each level, left and right. At
the L5 level the facet joint is innervated by the lateral brand of the S1 sacral foramen.
Facet joint pain is generally suspected in patients with cervical, thoracic and or lumbar
pain that may or may not have a radicular component, when focal tenderness is present
over the facet joint, and increased symptoms due to rotation or extension of the spine.
Destruction of a paravertebral facet joint nerve(s) requires the use of fluoroscopic
guidance to confirm the proper positioning of the needle or electrode at the level of the
involved paravertebral facet joint(s). Destruction of the paravertebral facet joint nerve (s)
(median branch) can then be achieved by means of thermal, electrical or radiofrequency
(rhizotomy) applications. Facet joint nerve destruction is considered a definitive form of
treatment for facet joint pain. Therefore, it would not be expected to see multiple repeat
facet joint destruction procedures performed once all of the involved facet joints at that
spinal level on either side have been denervated. However, the nerves do have the ability
to regenerate. If pain recurs in the same distribution and nature, the procedure may be
provided at a maximum of two (2) sessions per year (per 12 months).
The sacrum is the congenital fusion of five (5) vertebral bodies that are innervated by the
S1, S2, S3, and S4 lateral branches of the sacral foramen. Denervation of the sacroiliac
joint can be accomplished by destruction of the lateral branches of the sacral foramenal
nerves and requires the use of fluoroscopic guidance to confirm the proper positioning of
the needle or electrode at the level of the involved sacroiliac joint. Destruction of the
sacroiliac joint nerve (lateral branches) can then be achieved by means of thermal,
electrical or radiofrequency (rhizotomy) applications. Sacroiliac joint nerve destruction
is considered a definitive form of treatment for Sacroiliac joint pain. Therefore, it would
not be expected to see multiple joint destruction procedures performed on either side.
However, the nerves do have the ability to regenerate. If pain recurs in the same
distribution and nature, the procedure may be provided at a maximum of two (2) sessions
per year (per 12 months).
Indications
Medicare will consider the destruction of cervical, thoracic or lumbar paravertebral facet
joint (median branch) nerves and or the sacroiliac joint to be medically reasonable and
necessary as follows:
•
•
•
The paravertebral facet joint(s) and or the sacroiliac joint have been identified as
the source of the patient’s pain by undergoing a diagnostic paravertebral facet
joint (median branch) block and or a sacroiliac iliac joint injection. Temporary
or prolonged abolition of the pain suggests that the facet joint (s) or sacroiliac
joint are the source of the symptoms and appropriate for treatment; and
The patient failed conservative treatment. Conservative treatment may include
local heat, traction, nonsteroidal anti-inflammatory medications and anesthetic
and
The paravertebral facet joint(s) and sacroiliac joint destruction is performed by
appropriately trained providers. Training and expertise must have been acquired
within the framework of an accredited residency and/or fellowship program in the
applicable specialty/subspecialty. If this skill has been acquired as continuing
medical education, the courses must be comprehensive, offered, sponsored or
endorsed by an academic institution in the United States and/or by the applicable
specialty/subspecialty society in the United States, and designated by the
American Medical Association (AMA) as Category 1 Credit. Documentation of
training must be available upon request.
64475 (Lumbar Facet Injection) – We drafted the LCD for this last year. The same
would true for the diagnostic facet injection as above, but we are not working on this
LCD at this time.