Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download coolief* cooled radiofrequency reimbursement guide
Document related concepts
Transcript
COOLIEF* Cooled Radiofrequency Systems COOLIEF* COOLED RADIOFREQUENCY REIMBURSEMENT GUIDE Revised 06/2016 COOLIEF* Cooled Radiofrequency Systems HALYARD* Pain Management Cooled RF Systems Reimbursement Guide Table of Contents • Introduction........................................................................................................................... 2 • COOLIEF* TRANSDICAL* Disc Biacuplasty Cooled Radiofrequency........................ 3 • COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency............................................ 8 • COOLIEF* Cervical Cooled Radiofrequency................................................................ 15 • COOLIEF* Thoracic Cooled Radiofrequency...............................................................23 • COOLIEF* Lumbar Cooled Radiofrequency.................................................................29 • COOLIEF* Knee Cooled Radiofrequency...................................................................... 33 • COOLIEF* Hip Cooled Radiofrequency.........................................................................40 • Appeals..................................................................................................................................46 Introduction This reimbursement guide provides basic information regarding coding and coverage to assist you and your facility in obtaining reimbursement for our COOLIEF* Cooled RF procedures, which include: • COOLIEF* TRANSDICAL* Disc Biacuplasty Cooled Radiofrequency • COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency • COOLIEF* Cervical Cooled Radiofrequency • COOLIEF* Thoracic Cooled Radiofrequency • COOLIEF* Lumbar Cooled Radiofrequency • COOLIEF* Knee Cooled Radiofrequency • COOLIEF* Hip Cooled Radiofrequency Information contained in this reimbursement guide is derived from a variety of sources as of September 2015 and is intended for general information only. The intent of this guide is to assist providers in accurately obtaining coverage and reimbursement for healthcare services. It is not intended to increase or maximize reimbursement by any payer. Providers assume full responsibility for all claims submissions and reimbursement decisions. Each claim should be coded appropriately and supported with adequate documentation of the patient’s medical record. The codes listed in the guide are examples of codes that may be appropriate for individual situations. These codes do not represent correct coding for all procedures involving our various cooled RF technologies. 2 COOLIEF* Cooled Radiofrequency Systems COOLIEF* TRANSDISCAL* Disc Biacuplasty Cooled Radiofrequency The disc biacuplasty procedure uses the COOLIEF* TRANSDISCAL* Disc Biacuplasty Cooled Radofrequency. This procedure is performed to treat patients with chronic discogenic pain and contained herniated discs through a bipolar approach using internally water-cooled radiofrequency probes to coagulate and deactivate nerves while decompressing disc material. CPT® Codes: 22899: Unlisted procedure, spine OR 64999: Unlisted procedure, nervous system 77003: Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures Device Codes: There are no specific HCPCS codes (C Code or pass-through code) for the disc biacuplasty probe kit. The miscellaneous surgical supply code, A4649, can be used to bill for the single-use probe kit; however, it is at the payer’s discretion to provide additional reimbursement. Coverage: To support the use of an unlisted procedure code, a prior authorization from the payer is recommended. 3 COOLIEF* Cooled Radiofrequency Systems ICD-9/ICD-10 Diagnosis Codes: Following is a list of possible diagnosis codes which may support medical necessity for the disc biacuplasty procedure to treat the chronic pain caused by these medical conditions. This list is not intended to be an all-inclusive list. Other ICD-9 diagnostic codes may apply based on the patient’s diagnosis. The physician must always make the final determination of the appropriate diagnosis code. CPT® is a Registered Trademark of the American Medical Association. All rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained in this guide. The AMA assumes no responsibility for consequences attributable to or related to any use or interpretation of any information or views contained or not contained in this guide. ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 722.52 Degeneration of lumbar or lumbosacral intervertebarl disc M51.36 Other intervertebral disc degeneration,lumbar region M51.37 Other intervertebral disc degeneration,lumbosacral region M51.36 Other intervertebral disc degeneration,lumbar region M51.37 Other intervertebral disc degeneration,lumbosacral region M46.47 Discitis, unspecified, lumbosacral region M51.86 Other intervertebral disc disorders, lumbar region M51.87 Other intervertebral disc disorders, lumbosacral region 722.6 722.93 Degeneration of intervertebral disc, site uinspecified Other and unspecified disc disorder of lumbar region M46.46 Discitis, unspecified, lumbar region 724.2 Lumbago M54.5 Low back pain 724.8 Other symptoms referable to the back M54.08 Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region M54.06 Panniculitis affecting regions of neck and back, lumbar region M54.07 Panniculitis affecting regions of neck and back, lumbosacral region M54.09 Panniculitis affecting regions of neck and back,multiple sites in spine region 724.9 739.3 Other unspecified back disorders Nonallopathic lesions of lumbar region, not elsewhere classified M43.26 Fusion of spine,lumbar region M43.27 Fusion of spine,lumbosacral region M99.03 Segmental and somatic dysfuntion of lumbar region For a complete list of coding options and descriptions, consult the current ICD-10-CM manual. 4 COOLIEF* Cooled Radiofrequency Systems Pre-Authorization Process: Once a candidate has been identified, medical necessity has been established, and a Waiver of Financial Liability has been signed by the patient, a pre-authorization request should be submitted to the patient’s insurance carrier prior to performing the disc biacuplasty procedure. Note: Medicare does not have a pre-authorization process. It is recommended that a potential patient who is covered by Medicare sign an ABN (Advanced Beneficiary Notice). When submitting a pre-authorization request, the following steps should be taken: • Place a call to the payer to verify insurance benefits and determine if a pre-authorization is required. • Provide the payer with the patient’s diagnosis and the appropriate CPT® code • If a pre-authorization is required, documentation to support medical necessity will be required, which should be included in the letter of medical necessity (LOMN): • Patient’s brief medical history • Physician’s exam findings • Copies of pertinent reports (MRIs, CT scans, etc) • Alternative treatments previously tried • How the activities of daily life are being impacted by the medical condition • Duration of the diagnosis • Identification of the site of service (office, ASC, or hospital outpatient) Note: Payers base their decisions on medical necessity, as well as benefits, therefore we encourage you to make a strong case for the patient’s particular medical need for the disc biacuplasty procedure. 5 COOLIEF* Cooled Radiofrequency Systems Following is a sample letter of medical necessity for the COOLIEF* TRANSDISCAL* Disc Biacuplasty Cooled Radiofrequency procedure to assist you in drafting a pre-authorization request. SAMPLE LETTER OF MEDICAL NECESSITY [Date] Attn: [Contact] usually the medical director [Title] [Name of Health Insurance Company] [Address] [City, State, ZIP Code] RE: Treatment authorization request for [Patient Name] [Policy Number/Group Number/Patient ID#] [Date of Birth] Dear [Name of Contact] / [To Whom It May Concern]: I am writing on behalf of my patient, [name of patient], to document the medical necessity of performing the COOLIEF* TRANSDISCAL* Disc Biacuplasty Cooled Radiofrequency procedure. [Mr./Mrs./Ms.] [Patient’s last name] has been suffering from chronic discogenic pain for [xx] months. [Mr./Mrs./Ms.] [Patient’s last name]’s medical history and treatment information for chronic discogenic pain is as follows: • List previous conservative treatment(s) done on the patient (including use of drugs such as analgesics, opioids, anti-inflammatory drugs; physiotherapy; steroid injections) and their outcome(s) Despite these attempts, [Mr./Mrs./Ms.] [Patient’s last name] has received minimal relief from symptoms and is currently [describe patient’s current condition and how activities of daily life are affected]. I have included the results of tests which indicate [list findings from CT, MRI, etc., and attach any other tests performed to confirm diagnosis]. Due to the unsuccessful outcome(s) of previous treatment(s), I am of the medical opinion that [Mr./Mrs./Ms.] [Patient’s last name] would benefit from a procedure called COOLIEF* TRANSDISCAL* Disc Biacuplasty Cooled Radiofrequency. This procedure is medically necessary to treat [Mr./Mrs./Ms.] [Patient’s last name] for chronic discogenic pain. My recommended treatment has been successfully used in many cases. 6 COOLIEF* Cooled Radiofrequency Systems I am recommending a procedure called intervertebral disc biacuplasty at the [Specify Level] levels to ablate the nociceptors and nerve fibers that are responsible for discogenic pain within the degenerated disc. The procedure involves the use of the COOLIEF* Cooled RF System. The COOLIEF* Cooled RF System in combination with the HALYARD* COOLIEF* Pain Management Generator uses a bipolar approach with internally water-cooled radiofrequency probes to coagulate and deactivate nerves while decompressing disc material and aims to treat symptomatic patients with discogenic pain and contained herniated discs. [Mr./Mrs./Ms.] [Patient’s last name] quality of life is diminished as the pain severely interferes with his/her work, family and the community activities he [she] would normally be involved in. This procedure will be performed [Date] at [Facility] pending the authorization of this request. Please confirm this procedure will be covered for [Mr./Mrs./Ms.] [Patient’s last name] based on medical necessity. Contact me by phone at_________________________or by fax _________________________ if you have any questions. Thank you for your attention to this matter, and I look forward to your response. Sincerely, [Physician’s Name] [Physician’s Practice Name] Encl. (relevant diagnostic test(s) and result(s), patient’s pertinent medical history records etc.) 7 COOLIEF* Cooled Radiofrequency Systems COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency is designed to treat patients with chronic sacroiliac joint pain. This treatment utilizes an internally water-cooled radiofrequency probe to ablate the dorsal ramus of L5 and the lateral branches of the dorsal rami exiting from the posterior sacral foramen at S1, S2, and S3. CPT® Codes: 64635: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); lumbar or sacral, single facet joint 64640: Destruction by neurolytic agent; other peripheral nerve or branch RF denervation in the sacroiliac region is commonly done at L5, S1, S2, and S3 levels. Physicians who currently perform RF denervation procedure in the sacroiliac region commonly use the following approach in coding: RF lesion at L5/S1 facet joint: 64635 RF lesions at S1: 64640-59 RF lesions at S2: 64640-59 RF lesions at S3: 64640-59 Note: For bilateral procedures, use Modifier-50 Effective January 1, 2016 the AMA added guidelines for the facet joint denervation CPT codes (64633, 64634, 64635 and 64636) that state that these codes should not be used for nonthermal facet joint denervation including chemical, low-grade thermal energy (< 80 degrees Celsius), or any form of pulsed radiofrequency. Note: The “Cooled RF Temp” (default setting of 60 degrees C) displayed on the COOLIEF* Cooled RF Generator refers to the cooled electrode temperature and does not reflect the surrounding tissue temperature. The heat generated from the radiofrequency energy produces thermal energy with average maximum tissue temperature greater than 80 degrees C. According to the AMA, as published in the CPT Assistant, December 2009: “To differentiate between the work when performing sacral nerve destruction of S1, S2, S3, and S4, each individually separate peripheral nerve root neurolytic block is reported as destruction of a peripheral nerve, using code 64640, Destruction by neurolytic agent; other peripheral nerve or branch. In this instance, code 64640 is reported four times. It is suggested that Modifier 59, Distinct Procedural Service, be appended as well.” 8 COOLIEF* Cooled Radiofrequency Systems Device Codes: There are no specific HCPCS codes (C Code or pass-through code) for the SInergy* probe kit. The miscellaneous surgical supply code, A4649, can be used to bill for the single-use probe kit; however, it is at the payer’s discretion to provide additional reimbursement. Coverage: Coverage for RF denervation to treat sacroiliac joint pain varies significantly between payers. As a result, a prior authorization from the payer is recommended. 9 COOLIEF* Cooled Radiofrequency Systems ICD-9/ICD-10 Diagnosis Codes: Following is a list of possible diagnosis codes which may support medical necessity for the COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency Treatment to treat the chronic pain caused by these medical conditions. This list is not intended to be an all-inclusive list. Other ICD-9 diagnostic codes may apply based on the patient’s diagnosis. The physician must always make the final determination of the appropriate diagnosis code. ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 353.1 Lumbosacral plexus lesions G54.1 Lumbosacral plexus disorders 353.4 Lumbosacral root lesions, not elsewhere classified G54.4 Lumbosacral root disorders, not elsewhere classified 353.8 Other nerve root and plexus disorder G54.8 Other nerve root and plexus disorders G55 Nerve root and plexus compressions in diseases classified elsewhere 719.45 720.O Pain in joint, pelvic region and thigh Ankylosing spondylitis M25.551 Pain in right hip M25.552 Pain in left hip M45.0 Ankylosing spondylitis of multiple sites in spine M45.7 Ankylosing spondylitis of lumbosacral region M45.8 Ankylosing spondylitis sacral and sacrococcygeal region M48.8X7 Other specified spondylopathies lumbosacral region M48.8X8 Other specified spondylopathies sacral and sacrococcygeal region 720.2 Sacroilitis M46.1 Sacroiliitis, not elsewhere classified 721.3 Lumbosacral spondylosis without myelopathy M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region M47.26 Other spondylosis with radiculopathy, lumbar region M47.27 Other spondylosis with radiculopathy, lumbosacral region M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region M47.896 Other spondylosis, lumbar region M47.897 Other spondylosis, lumbosacral region 724.2 Lumbago M54.5 Low back pain 724.3 Sciatica M54.30 Sciatica, unspecified side M54.31 Sciatica, right side M54.32 Sciatica, left side M54.40 Lumbago with sciatica, unspecified side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M43.27 Fusion of spine, lumbosacral region M43.28 Fusion of spine, sacral and sacrococcygeal region 724.6 Disorders of the sacrum 10 COOLIEF* Cooled Radiofrequency Systems ICD-9 CODE 724.8 739.4 756.12 DESCRIPTION Other symptoms referable to the back Nonallopathic lesions of sacral region, not elsewhere classified Cogenital spondylolisthesis ICD-10 CODE DESCRIPTION M53.2X7 Spinal instabilities, lumbosacral region M53.2X8 Spinal instabilities, sacral and sacrococcygeal region M53.86 Other specified dorsopathies, lumbar region M53.87 Other specified dorsopathies, lumbosacral region M53.88 Other specified dorsopathies, sacral and sacrococcygeal region M54.08 Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region M54.07 Panniculitis affecting regions of neck and back, lumbosacral region M54.17 Radiculopathy, lumbosacral region M99.04 Segmental and somatic dysfunction of sacral region M99.05 Segmental and somatic dysfunction of pelvic region Q76.2 Congenital spondylolisthesis For a complete list of coding options and descriptions, consult the current ICD-10-CM manual. 11 COOLIEF* Cooled Radiofrequency Systems Pre-Authorization Process: Once a candidate has been identified, medical necessity has been established, and a Waiver of Financial Liability has been signed by the patient, a pre-authorization request should be submitted to the patient’s insurance carrier prior to performing the COOLIEF* SINERGY* Sacroiliac Cooled RF Treatment. Note: Medicare does not have a pre-authorization process. It is recommended that a potential patient that is covered by Medicare sign an ABN (Advanced Beneficiary Notice). When submitting a pre-authorization request, the following steps should be taken: • Place a call to the payer to verify insurance benefits and determine if a pre-authorization is required. • Provide the payer with the patient’s diagnosis and the appropriate CPT® code • If a pre-authorization is required, documentation to support medical necessity will be required which should be included in the letter of medical necessity (LOMN): • Patient’s brief medical history • Physician’s exam findings • Copies of pertinent reports (MRIs, CT scans, etc) • Alternative treatments previously tried • How the activities of daily life are being impacted by the medical condition • Duration of the diagnosis • Identification of the site of service (office; ASC; or hospital outpatient) Note: Payers base their decisions on medical necessity, as well as benefits; therefore we encourage you to make a strong case for the patient’s particular medical need for the sacroiliac joint neurotomy procedure. 12 COOLIEF* Cooled Radiofrequency Systems Following is a sample letter of medical necessity for the COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency procedure to assist you in drafting a pre-authorization request. SAMPLE LETTER OF MEDICAL NECESSITY [Date] Attn: [Contact] usually the medical director [Title] [Name of Health Insurance Company] [Address] [City, State, ZIP Code] RE: Treatment authorization request for [Patient Name] [Policy Number/Group Number/Patient ID#] [Date of Birth] Dear [Name of Contact] / [To Whom It May Concern]: I am writing on behalf of my patient, [name of patient], to document the medical necessity of sacroiliac joint neurotomy procedure. [Mr./Mrs./Ms.] [Patient’s last name] has been suffering from chronic pain associated with the sacroiliac joint complex for [xx] months. [Mr./Mrs./Ms.] [Patient’s last name]’s medical history and treatment information for chronic pain associated with the sacroiliac joint complex is as follows: • List previous conservative treatment(s) done on the patient (including use of drugs such as analgesics, opioids, anti-inflammatory drugs; physiotherapy; steroid injections) and their outcome(s) Despite these attempts, [Mr./Mrs./Ms.] [Patient’s last name] has received minimal relief from symptoms and is currently [describe patient’s current condition and how activities of daily life are affected]. I have included the results of tests which indicate [list findings from CT, MRI, etc., and attach any other tests performed to confirm diagnosis]. Due to the unsuccessful outcome(s) of previous treatment(s), I am of the medical opinion that [Mr./Mrs./Ms.] [Patient’s last name] would benefit from a procedure called sacroiliac joint neurotomy. This procedure is medically necessary to treat [Mr./Mrs./Ms.] [Patient’s last name] for chronic pain associated with the sacroiliac joint complex. My recommended treatment has been successfully used in many cases. 13 COOLIEF* Cooled Radiofrequency Systems The sacroiliac joint neurotomy procedure is performed using the HALYARD* COOLIEF* SINERGY* Sacroiliac Cooled RF Pain Management System. The The COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency Treatment is comprised of COOLIEF* SINERGY* Probe Kit, COOLIEF* SINERGY* Introducer, Pain Management Pump Unit and Cable, Pain Management Tube kit, Dispersive Electrode and Connecting Cable. This system is used in conjunction with a Radiofrequency Generator to create radiofrequency lesions in the nervous tissue. The procedure ablates the dorsal ramus of L5 that runs along the sacral ala and the lateral branches of the dorsal rami exiting from posterior sacral foramen at S1, S2 and S3. These nerves are known to innervate the sacroiliac joint and are responsible for the pain associated with sacroiliac joint syndrome. Because of the complex, varied and diffuse innervations in the sacroiliac region, large radiofrequency lesions are required to ensure complete ablation of the nervous tissue. A cooled probe allows a sufficiently large volume of tissue to be heated without excessively heating tissue adjacent the probe tip. In summary, sacroiliac joint neurotomy procedure using the HALYARD* COOLIEF* SINERGY* Sacroiliac Cooled RF Pain Management System is necessary and reasonable for [Mr./Mrs./ Ms.] [Patient’s last name]’s medical condition. Based on the diagnostic results, I firmly believe that [Mr./Mrs./Ms.] [Patient’s last name] is an excellent candidate for this procedure and I request you to consider a prompt approval for this procedure. Thank you for your attention to this matter, and I look forward to your response. Sincerely, [Physician’s Name] [Physician’s Practice Name] Encl. (relevant diagnostic test(s) and result(s), patient’s pertinent medical history records etc. Note: This information is not intended to serve as specific advice on how to code, bill, or charge for any service. It is always the provider’s responsibility to determine appropriate codes. You may wish to contact your local payer for interpretation of appropriate codes and coverage policies. CPT is a registered trademark of the American Medical Association. CPT codes ©2005 American Medical Association. All rights reserved. 14 COOLIEF* Cooled Radiofrequency Systems COOLIEF* Cervical Cooled Radiofrequency COOLIEF* Cervical Cooled Radiofrequency is designed to treat the pain associated with cervical Z-joint through the use of an internally water-cooled radiofrequency probe to ablate the medial branches coursing over the superolateral aspect of the transverse process of the cervical spine. CPT® Codes: 64633: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); cervical or thoracic, single facet joint 64634: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); cervical or thoracic, each additional facet joint Cervical medial branch neurotomy procedures are commonly performed at levels from C3 to C7. An example of coding commonly used by physicians performing cervical medial branch neurotomy is listed below: RF lesion at C 3/4 facet joint: 64633 RF lesion at C 4/5 facet joint: 64634 RF lesion at C 5/6 facet joint: 64634 Note: For bilateral procedures, use Modifier-50 Effective January 1, 2016 the AMA added guidelines for the facet joint denervation CPT codes (64633, 64634, 64635 and 64636) that state that these codes should not be used for nonthermal facet joint denervation including chemical, low-grade thermal energy (< 80 degrees Celsius), or any form of pulsed radiofrequency. Note: The “Cooled RF Temp” (default setting of 60 degrees C) displayed on the COOLIEF* Cooled RF Generator refers to the cooled electrode temperature and does not reflect the surrounding tissue temperature. The heat generated from the radiofrequency energy produces thermal energy with average maximum tissue temperature greater than 80 degrees C. Device Codes: There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* Probe Kit. The miscellaneous surgical supply code, A4649, can be used to bill for the single-use probe kit; however, it is at the payer’s discretion to provide additional reimbursement. Coverage: Most commercial payers and medicare provide coverage for RF Denervation to treat cervical facet joint pain. Requirements and limitations will vary between payers. Please check with the patient’s insurance for their specific coverage policy on RF Denervation for cervical facet. 15 COOLIEF* Cooled Radiofrequency Systems ICD-9/ICD-10 Diagnosis Codes: Following is a list of possible diagnosis codes which may support medical necessity for RF denervation of cervical facet nerves to treat the chronic pain caused by these medical conditions. This list is not intended to be an all-inclusive list. Other ICD-9 diagnostic codes may apply based on the patient’s diagnosis. The physician must always make the final determination of the appropriate diagnosis code.ICD-9-CM ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 333.83 Spasmodic torticollis/cervical dystonia G24.3 Spasmodic torticollis 338.4 Chronic pain syndrome G89.4 Chronic pain syndrome 350.2 Atypical face pain G50.1 Atypical face pain 353.2 Cervical root lesions not elsewhere classified G54.2 Cervical root disorders not elsewhere classified 721.O Cervical spondylosis without myelopathy M47.812 Spondylosis without myelopathy or radiculopathy, cervical region M47.21 Other spondylosis with radiculopathy, occipito-atlanto-axial region M47.22 Other spondylosis with radiculopathy, cervical region M47.23 Other spondylosis with radiculopathy, cervicothoracic region M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region M47.891 Other spondylosis, occiiito-atlanto-axial region M47.892 Other spondylosis, cervical region M47.893 Other spondylosis, cervicothoracic region M47.12 Other spondylosis with myelopathy, cervical region M47.011 Anterior spinal artery compression syndromes, occipito-atlanto-axial region M47.012 Anterior spinal artery compression syndromes, cervical region M47.013 Anterior spinal artery compression syndromes, cervicothoracic region M47.021 Vertebral artery compression syndromes, occipito-atlanto-axial region M47.022 Vertebral artery compression syndromes, cervical region M47.11 Other spondylosis with myelopathy, occipito-atlanto-axial region M47.13 Other spondylosis with myelopathy, cervicothoracic region M50.20 Other cervical disc displacement, unspecified cervical region M50.21 Other cervical disc displacement, high cervical region M50.22 Other cervical disc displacement, midcervical region 721.1 722.O Cervical spondylosis with myelopathy Displacement of cervical intervertebral disc without myelopathy 16 COOLIEF* Cooled Radiofrequency Systems ICD-9 CODE 722.4 722.71 723.O DESCRIPTION Degeneration of cervical intervertebral disc Intervertebral disc disorder with myelopathy cervical region Spinal stenosis in cervical region ICD-10 CODE DESCRIPTION M50.23 Other cervical disc displacement, cervicothoracic region M50.30 Other cervical disc degeneration, unspecified cervical region M50.31 Other cervical disc degeneration, high cervical region M50.32 Other cervical disc degeneration,midcervical region M50.33 Other cervical disc degeneration, cervicothoracic region M50.00 Cervical disc disorder with myelopathy, unspecified cervical region M50.01 Cervical disc disorder with myelopathy, high cervical region M50.02 Cervical disc disorder with myelopathy, mid-cervical region M50.03 Cervical disc disorder with myelopathy, cervicothoracic region M48.02 Spinal stenosis, cervical region M48.01 Spinal stenosis, occipito-atlanto-axial region M48.03 Spinal stenosis, cervicothoracic region M99.21 Subluxation stenosis of neural canal of cervical region M99.31 Osseous stenosis of neural canal of cervical region M99.41 Connective tissue stenosis of neural canal of cervical region M99.51 Intervertebral disc stenosis of neural canal of cervical regiion M99.61 Osseous and subluxation stenosis of intervertebral foramina of cervical region M99.71 Connective tissue and disc stenosis of intervertebral foramina of cervical region 723.1 Cervicalgia M54.2 Cervicalgia 723.4 Radiculopathy neuritis cervical/brachial M54.12 Radiculopathy, cervical region M54.13 Radiculopathy, cervicothoracic region M50.10 Cervical disc disorder with radiculopathy, unspecified cervical region M50.11 Cervical disc disorder with radiculopathy, high cervical region M50.12 Cervical disc disorder with radiculopathy,mid-cervical region M50.13 Cervical disc disorder with radiculopathy, cervicothoracic region M54.11 Radiculopathy, occipito-atlanto-axial region M53.82 Other specified dorsopathies, cervical region M53.81 Other specified dorsopathies, occipitoatlanto-axial region M53.83 Other specified dorsopathies, cervicothoracic region M54.81 Occipital neuralgia 723.8 Occipital neuralgia 17 COOLIEF* Cooled Radiofrequency Systems 724.8 733.13 847.O 953.O Facet syndrome- lumbar, cervical, thoracic Compression fracture (vertebral) Neck sprain Injury to cervical nerve root M54.03 Panniculitis affecting regions of neck and back, cervicothoracic region M54.09 Panniculitis affecting regions of neck and back, multiple sites in spine M80.08XA Age-related osteopororosis with current pathologiacl fracture,vertebra€, initial encounter for fracture M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture M48.51XA Collapsed verterbra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture M48.52XA Collapsed verterbra, not elsewhere classified, cervical region, initial encounter for fracture M48.53XA Collapsed verterbra, not elsewhere classified, cervicothoracic region, initial encounter for fracture M80.88XA Other osteoporosis with current pathological fracture, vertebra€, initial encounter M84.58XA Pathological fracture in neoplastic disease, other specified site, initial encounter S13.4XXA Sprain of ligaments of cervical spine, initial encounter S13.8XXA Sprain of joints and ligaments of other parts of neck, initial encounter S16.1XXA Strain of muscle, fascia and tendon at neck level, initial encounter S14.2XXA Injury of nerve root of cervical spine, initial encounter For a complete list of coding options and descriptions, consult the current ICD-10-CM manual. Pre-Authorization Process: Once a candidate has been identified, medical necessity has been established, and a Waiver of Financial Liability has been signed by the patient, a pre-authorization request should be submitted to the patient’s insurance carrier prior to performing the COOLIEF* Cervical Cooled Radiofrequency Treatment. Note: Medicare does not have a pre-authorization process. It is recommended that a potential patient that is covered by Medicare sign an ABN (Advanced Beneficiary Notice). When submitting a pre-authorization request, the following steps should be taken: • Place a call to the payer to verify insurance benefits and determine if a pre-authorization is required. • Provide the payer with the patient’s diagnosis and the appropriate CPT® code • If a pre-authorization is required, documentation to support medical necessity will be required which should be included in the letter of medical necessity (LOMN): • Patient’s brief medical history • Physician’s exam findings • Copies of pertinent reports (MRIs, CT scans, etc) 18 COOLIEF* Cooled Radiofrequency Systems • Alternative treatments previously tried • How the activities of daily life are being impacted by the medical condition • Duration of the diagnosis • Identification of the site of service (office; ASC; or hospital outpatient) Note: Payers base their decisions on medical necessity, as well as benefits, therefore we encourage you to make a strong case for the patient’s particular medical need for the cervical medial branch neurotomy procedure. 19 COOLIEF* Cooled Radiofrequency Systems Following is a sample letter of medical necessity for the COOLIEF* Cervical Cooled Radiofrequency procedure to assist you in drafting a pre-authorization request. SAMPLE LETTER OF MEDICAL NECESSITY [Date] [Payer Address] Re: [Insert patient name and subscriber number] Dear [Medical Director]: Please consider this letter a request for preauthorization of benefits to treat my patient, [insert patient name], who suffers from [insert patient ICD-10-CA diagnosis code and description of procedure]. It is my clinical judgment that [Mr./Ms. insert patient last name] is an ideal candidate for radiofrequency (RF) denervation in the cervical region utilizing the HALYARD* COOLIEF* Cervical Cooled RF Pain Management System, and prior to scheduling this procedure I am seeking preauthorization and predetermination of benefits for my patient. Patient History [Mr./Ms. insert patient name] presented to me with complaints of [insert detailed patient history with description of patient’s current condition including diagnosis, length of time problem has existed, current/ ongoing complaints, and level of impairment. Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life.] Previous interventional treatment efforts include: [indicate procedures, medications, and/or therapies attempted – include outcome of each treatment]. Despite these treatments and therapies, [Mr./Ms. insert patient name] has experienced no significant relief from [insert specific symptoms here]. A problem-focused history and exam was performed as well as [indicate scans, MRIs, X-rays, nerve blocks etc]. The findings of these test results confirm my diagnosis of [insert patient diagnosis code] and support my request for treatment. 20 COOLIEF* Cooled Radiofrequency Systems Proposed Treatment I am recommending a radiofrequency denervation procedure for the ablation of medial branch nerves in the cervical region. The procedure involves the use of the HALYARD* COOLIEF* Cervical Cooled RF Pain Management System to create targeted lesions at the medial branches of the cervical dorsal rami. These nerves are known to innervate the cervical zygapophysial joints (z-joints) and are associated with cervical z-joint pain. Because of the varied innervations in the cervical region, large radiofrequency lesions are required to ensure complete ablation of the nervous tissue. Cooled RF technology utilized by the COOLIEF* Cervical Cooled RF Pain Management System allows a large volume of tissue to be heated (without excessively heating tissue adjacent to the probe tip) compared to conventional radiofrequency electrodes. This procedure will be performed on [indicate anticipated date of procedure] at [indicate site of service and name of facility where the procedure will be performed – physician office, outpatient hospital]. Please confirm if there are any restrictions on performing this procedure in this setting. Please confirm this procedure will be covered for [insert patient name] based on medical necessity. Please contact me at [insert phone number] if you have any questions. Sincerely, [Doctor signature] Dr. [doctor name] 21 COOLIEF* Cooled Radiofrequency Systems Sample Operative Note COOLIEF* CERVICAL COOLED RADIOFREQUENCY Reference Material Only COOLIEF* CERVICAL COOLED RADIOFREQUENCY PATIENT NAME: MRN: PHYSICIAN: PREOPERATIVE DIAGNOSIS: POSTOPERATIVE DIAGNOSIS: PROCEDURE: 1. C3 facet joint radiofrequency denervation 2. C4 facet joint radiofrequency denervation 3. C5 facet joint radiofrequency denervation DATE OF PROCEDURE: ANESTHESIA: MAC COMPLICATIONS: None ESTIMATED BLOOD LOSS: Minimal PROCEDURE IN DETAIL: informed consent was given and signed informed consent document was obtained. A full description of the procedure was provided including benefits, as well as possible complications including transient increased pain, short term tremulusness, headaches, stomach irritation, mood alteration, as well as more uncommon nerve injury, bleeding, infection or allergic reaction The patient was brought to the operating room and placed on the exam table in a comfortable prone position. The place for the needle placement was obtained by manual palpation as well as radiographic confirmation. The sterile field was prepped by chlorhexidine and sterile drapes. Local anesthesia, both superficial and deep was provided by local infiltration of 8 ml Lidocaine 1%. Using fluoroscopic guidance, a 17-gauge (50mm/75mm) insulated sharp radiofrequency needle with a 2 mm active tip was placed overlying the right C4 cervical vertebra from the posterior approach and was advanced until bony contact was felt with the articular pillar. The needle was walked off the pillar, maintaining contact with the bone. Attempted aspiration revealed no blood or cerebrospinal fluid. Radiographs were then made in AP and lateral. Motor testing was then performed with 2.0 volts and no upper extremity motor stimulation was observed. 1 cc of the 5ml Lidocaine was injected through the RF needle. A thermal radiofrequency lesion of the medial branch of C4 was then performed at an average maximum tissue temperature greater than 80 degrees C for 2 minutes and 30 seconds. The same procedure was repeated for bilateral C5 and C6 medial branches. The patient tolerated the procedure well. He was taken to recovery in good condition. He was provided with instructions as to what to expect. He was also provided with contact information and instructed to call regarding any concerning symptoms or questions. Registered Trademark or Trademark of Halyard Health, Inc. and its affiliates. IMPRESSION: HYH. All rights reserved.C4, C5, and C6 cervical medial branch radiofrequency ablation. w Successful 1.©2015 bilateral ww.HalyardHealth.com 2.For more Follow-up in 3 weeks to assess the efficacy of this procedure. information, call 1-800-524-3577 22 COOLIEF* Cooled Radiofrequency Systems COOLIEF* Thoracic Cooled Radiofrequency COOLIEF* Thoracic Cooled Radiofrequency is designed to treat the pain associated with thoracic Z-joint through the use of an internally water-cooled radiofrequency probe to ablate the medial branches coursing over the superolateral aspect of the transverse process of the thoracic spine. CPT® Codes: 64633: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); cervical or thoracic, single facet joint 64634: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); cervical or thoracic, each additional facet joint Thoracic medial branch neurotomy procedures are commonly performed at levels from T1 to T12. An example of coding commonly used by physicians performing thoracic medial branch neurotomy is listed below: RF lesion at T3-4 facet joint: 64633 RF lesion at T4-5 facet joint: 64634 RF lesion at T5-6 facet joint: 64634 Note: For bilateral procedures, use Modifier-50 Effective January 1, 2016 the AMA added guidelines for the facet joint denervation CPT codes (64633, 64634, 64635 and 64636) that state that these codes should not be used for nonthermal facet joint denervation including chemical, low-grade thermal energy (< 80 degrees Celsius), or any form of pulsed radiofrequency. Note: The “Cooled RF Temp” (default setting of 60 degrees C) displayed on the COOLIEF* Cooled RF Generator refers to the cooled electrode temperature and does not reflect the surrounding tissue temperature. The heat generated from the radiofrequency energy produces thermal energy with average maximum tissue temperature greater than 80 degrees C. Device Codes: There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* Probe Kit. The miscellaneous surgical supply code, A4649, can be used to bill for the single-use probe kit; however, it is at the payer’s discretion to provide additional reimbursement. Coverage: Coverage for RF denervation to treat thoracic facet joint pain varies significantly between payers. As a result, a prior authorization from the payer is recommended. 23 COOLIEF* Cooled Radiofrequency Systems ICD-9/ICD-10 Diagnosis Codes: Following is a list of possible diagnosis codes which may support medical necessity for RF denervation of thoracic facet nerves to treat the chronic pain caused by these medical conditions. This list is not intended to be an all-inclusive list. Other ICD-9 diagnostic codes may apply based on the patient’s diagnosis. The physician must always make the final determination of the appropriate diagnosis code. ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 353.3 Thoracic root lesions, not elsewhere classified G54.3 Thoracic root disorders, not elsewhere classified 353.8 Other nerve root and plexus disorder G54.8 Other nerve root and plexus disorders G55 Nerve root and plexus compressios in diseases classified elsewhere M45.0 Ankylosing spondylitis of multiple sites in spine M45.3 Ankylosing spondylitis of cervicothoracic region M45.4 Ankylosing spondylitis of thoracic region M45.5 Ankylosing spondylitis of thoracolumbar region M48.8X3 Other specified spondylopathies, cervicothoracic region M48.8X4 Other specified spondylopathies, thoracic region M48.8X5 Other specified spondylopathies, thoracolumbar region M48.8X9 Other specified spondylopathies, site unspecifiedthoracolumbar region M46.03 Spinal enthesopathy, cervicothoracic region M46.94 Spinal enthesopathy, thoracic region M46.05 Spinal enthesopathy, thoracolumbar region M46.09 Spinal enthesopathy, multiple sites in spine M47.814 Spondylosis without myelopathy or radiculopathy, thoracic region M47.24 Other spondylosis with radiculopathy, thoracic region M47.25 Other spondylosis with radiculopathy, thoracolumbar region M47.815 Spondylosis without myelopathy or radiculopathy, thoracolumbar region M47.894 Other spondylosis, thoracic region M47.895 Other spondylosis, thoracolumbar region M48.13 Ankylosing hyperostosis (Forestier), cervicothoracic region M48.14 Ankylosing hyperostosis (Forestier), thoracic region M48.15 Ankylosing hyperostosis (Forestier), thoracolumbar region M48.19 Ankylosing hyperostosis (Forestier), multiple sites in spine 720.O 720.1 721.2 721.6 Ankylosing spondylitis Spinal enthesopathy Thoracic spondylosis without myelopathy Ankylosing vertebral hyperostosis 24 COOLIEF* Cooled Radiofrequency Systems ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 721.7 Traumatic spondylopathy M48.33 Traumatic spondylopathy, cervicothoracic region M48.34 Traumatic spondylopathy, thoracic region M48.35 Traumatic spondylopathy, thoracolumbar region 722.82 Postlqaminectomy syndrome, thoracic region M96.1 Postlaminectomy syndrome, not elsewhere classified 724.1 Pain in thoracic spine M54.6 Pain in thoracic spine 724.4 Thoracic or lumbosacral neuuritis or radiculitis, unspecified M54.14 Radiculopathy, thoracic region M54.15 Radiculopathy, thoracolumbar region M51.14 Intervertebral disc disorders with radiculopathy, thoracic region M51.15 Intervertebral disc disorders with radiculopathy, thoracolumbar region M54.03 Panniculitis affecting regions of neck and back, cervicothoracic region M54.04 Panniculitis affecting regions of neck and back,thoracic region M54.05 Panniculitis affecting regions of neck and back,thoracolumbar region M54.09 Panniculitis affecting regions of neck and back,multiple sites in spine M79.2 Neuralgia and neuritis, unspecified 724.8 729.2 Other symptoms referable to the back Unspecified neuralgia, neuritis, and radiculitis For a complete list of coding options and descriptions, consult the current ICD-10-CM manual. 25 COOLIEF* Cooled Radiofrequency Systems Pre-Authorization Process: Once a candidate has been identified, medical necessity has been established, and a Waiver of Financial Liability has been signed by the patient, a pre-authorization request should be submitted to the patient’s insurance carrier prior to performing the COOLIEF* Thoracic Cooled Radiofrequency procedure. Note: Medicare does not have a pre-authorization process. It is recommended that a potential patient that is covered by Medicare sign an ABN (Advanced Beneficiary Notice). When submitting a pre-authorization request, the following steps should be taken: • Place a call to the payer to verify insurance benefits and determine if a pre-authorization is required. • Provide the payer with the patient’s diagnosis and the appropriate CPT® code • If a pre-authorization is required, documentation to support medical necessity will be required which should be included in the letter of medical necessity (LOMN): • Patient’s brief medical history • Physician’s exam findings • Copies of pertinent reports (MRIs, CT scans, etc) • Alternative treatments previously tried • How the activities of daily life are being impacted by the medical condition • Duration of the diagnosis • Identification of the site of service (office; ASC; or hospital outpatient) Note: Payers base their decisions on medical necessity, as well as benefits, therefore we encourage you to make a strong case for the patient’s particular medical need for the thoracic medial branch neurotomy procedure. 26 COOLIEF* Cooled Radiofrequency Systems Following is a sample letter of medical necessity for the COOLIEF* Thoracic Cooled Radiofrequency procedure to assist you in drafting a pre-authorization request. SAMPLE LETTER OF MEDICAL NECESSITY [Date] [Payer Address] Re: [Insert patient name and subscriber number] Dear [Medical Director]: Please consider this letter a request for preauthorization of benefits to treat my patient, [insert patient name], who suffers from [insert patient ICD-10-CA diagnosis code and description of procedure]. It is my clinical judgment that [Mr./Ms. insert patient last name] is an ideal candidate for radiofrequency (RF) denervation in the thoracic region utilizing the HALYARD* COOLIEF* Thoracic Cooled RF Pain Management System, and prior to scheduling this procedure I am seeking preauthorization and predetermination of benefits for my patient. Patient History [Mr./Ms. insert patient name] presented to me with complaints of [insert detailed patient history with description of patient’s current condition including diagnosis, length of time problem has existed, current/ ongoing complaints, and level of impairment. Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life.] Previous interventional treatment efforts include: [indicate procedures, medications, and/or therapies attempted – include outcome of each treatment]. Despite these treatments and therapies, [Mr./Ms. insert patient name] has experienced no significant relief from [insert specific symptoms here]. A problem-focused history and exam was performed as well as [indicate scans, MRIs, X-rays, nerve blocks etc]. The findings of these test results confirm my diagnosis of [insert patient diagnosis code] and support my request for treatment. Proposed Treatment I am recommending a radiofrequency denervation procedure for the ablation of medial branch nerves in the thoracic region. The procedure involves the use of the HALYARD* COOLIEF* Thoracic Cooled RF Pain Management System to create targeted lesions at the medial branches of the thoracic dorsal rami. These nerves are known to innervate the thoracic zygapophysial 27 COOLIEF* Cooled Radiofrequency Systems joints (z-joints) and are associated with thoracic z-joint pain. Because of the varied innervations in the thoracic region, large radiofrequency lesions are required to ensure complete ablation of the nervous tissue. Cooled RF technology utilized by the COOLIEF* Thoracic Cooled RF Pain Management System allows a large volume of tissue to be heated (without excessively heating tissue adjacent to the probe tip) compared to conventional radiofrequency electrodes. This procedure will be performed on [indicate anticipated date of procedure] at [indicate site of service and name of facility where the procedure will be performed – physician office, outpatient hospital]. Please confirm if there are any restrictions on performing this procedure in this setting. Please confirm this procedure will be covered for [insert patient name] based on medical necessity. Please contact me at [insert phone number] if you have any questions. Sincerely, [Doctor signature] Dr. [doctor name] 28 COOLIEF* Cooled Radiofrequency Systems COOLIEF* Lumbar Cooled Radiofrequency The COOLIEF* Lumbar Cooled Radiofrequency is designed to treat the pain associated with lumbar Z-joint pain through the use of an internally water-cooled radiofrequency probe to ablate the medial branches coursing over the base of the superior articular process of the lumbar spine. CPT® Codes: 64635: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); lumbar or sacral, single facet joint 64636: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT); lumbar or sacral, each additional facet joint Lumbosacral medial branch neurotomy procedures are commonly performed at levels from L1 to L5. An example of coding commonly used by physicians performing lumbar medial branch neurotomy is listed below: RF lesion at L3-4 facet joint: 64635 RF lesion at L4-5 facet joint: 64636 RF lesion at L5/S1 facet joint: 64636 Note: For bilateral procedures, use Modifier-50 Effective January 1, 2016 the AMA added guidelines for the facet joint denervation CPT codes (64633, 64634, 64635 and 64636) that state that these codes should not be used for nonthermal facet joint denervation including chemical, low-grade thermal energy (< 80 degrees Celsius), or any form of pulsed radiofrequency. Note: The “Cooled RF Temp” (default setting of 60 degrees C) displayed on the COOLIEF* Cooled RF Generator refers to the cooled electrode temperature and does not reflect the surrounding tissue temperature. The heat generated from the radiofrequency energy produces thermal energy with average maximum tissue temperature greater than 80 degrees C. Device Codes: There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* Probe Kit. The miscellaneous surgical supply code, A4649, can be used can be used to bill for the singleuse probe kit; however, it is at the payer’s discretion to provide additional reimbursement. Coverage: Most commercial payers and Medicare provide coverage for RF denervation to treat lumbar facet joint pain. Requirements and limitations will vary between payers. Please check with the patient’s insurance for their specific coverage policy on RF denervation for lumbar facet nerves. 29 COOLIEF* Cooled Radiofrequency Systems ICD-9/ICD-10 Diagnosis Codes: Following is a list of possible diagnosis codes which may support medical necessity for RF denervation of lumbar facet nerves to treat the chronic pain caused by these medical conditions. This list is not intended to be an all-inclusive list. Other ICD-9 diagnostic codes may apply based on the patient’s diagnosis. The physician must always make the final determination of the appropriate diagnosis code. ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 353.1 Lumbosacral plexus lesions G54.1 Lumbosacral plexus disorders 353.4 Lumbosacral root lesions, not elsewhere classified G54.4 Lumbosacral root disorders, not elsewhere classified 353.8 Other nerve root and plexus disorder G54.8 Other nerve root and plexus disorders G55 Nerve root and plexus compressions in diseases classified elsewhere G57.01 Lesion of sciatic nerve,right lower limb G57.02 Lesion of sciatic nerve, left lower limb M25.551 Pain in right hip M25.552 Pain in left hip M46.00 Spinal enthesopathy, site unspecified M46.06 Spinal enthesopathy, lumbar region M46.07 Spinal enthesopathy, lumbosacral region M46.09 Spinal enthesopathy, multiple sites in spine M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region M47.26 Other spondylosis with radiculopathy, lumbar region M47.27 Other spondylosis with radiculopathy, lumbosacral region M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region M47.896 Other spondylosis, lumbar region M47.897 Other spondylosis, lumbosacral region M48.10 Ankylosing hyperostosis (Forestier), site unspecified M48.16 Ankylosing hyperostosis (Forestier), lumbar region M48.17 Ankylosing hyperostosis (Forestier), lumbosacral region M48.19 Ankylosing hyperostosis (Forestier), multiple sites in spine M48.36 Traumatic spondylopathy, lumbar region M48.37 Traumatic spondylopathy, lumbosacral region 355.O 719.45 720.1 721.3 721.6 721.7 Lesion of sciatic nerve Pain in joint, pelvic region and thigh Spinal enthesopathy Lumbosacral spondylosis without myelopathy Ankylosing vertebral hyperostosis Traumatic spondylopathy 722.83 Postlaminectomy syndrome, lumbar region M96.1 Postlaminectomy syndrome, not elsewhere classified 722.93 Other and unspecified disc disorder, lumbar region M46.47 Discitis, unspecified, lumbosacral region M51.86 Other intervertebral disc disorders, lumbar region M51.87 Other intervertebral disc disorders, lumbosacral region M46.46 Discitis, unspecified, lumbar region 30 COOLIEF* Cooled Radiofrequency Systems ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 724.02 Spinal stenosis of the lumbar region M48.06 Spinal stenosis, lumbar region M48.07 Spinal stenosis, lumbosacral region M99.23 Subluxation stenosis of neural canal of lumbar region M99.33 Osseous stenosis of neural canal of lumbar region M99.43 Connective tissue stenosis of neural canal of lumbar region M99.53 Intervertebral disc stenosis of neural canal of lumbar regiion M99.63 Osseous and subluxation stenosis of intervertebral foramina of lumbar region M99.73 Connective tissue and disc stenosis of intervertebral foramina of lumbar region 724.2 Lumbago M54.5 Low back pain 724.3 Sciatica M54.30 Sciatica, unspecified side M54.31 Sciatica, right side M54.32 Sciatica, left side M54.40 Lumbago with sciatica, unspecified side M54.41 Lumbago with sciatica, right side M54.42 Lumbago with sciatica, left side M54.16 Radiculopathy, lumbar region M54.17 Radiculopathy, lumbosacral region M51.16 Intervertebral disc disorders with radiculopathy, lumbar region M51.17 Intervertebral disc disorders with radiculopathy, lumbosacral region 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified 724.5 Unspecified backache M54.89 Other dorsalgia 724.6 Disorders of the sacrum M43.27 Fusion of spine, lumbosacral region M53.2X7 Spinal instabilities, lumbosacral region M53.86 Other specified dorsopathies, lumbar region M53.87 Other specified dorsopathies, lumbosacral region M54.06 Panniculitis affecting regions of neck and back, lumbar region M54.07 Panniculitis affecting regions of neck and back, lumbosacral region M54.09 Panniculitis affecting regions of neck and back,multiple sites in spine M43.8X9 Other specified deforming dorsopathies, site unspecified M43.26 Fusion of spine, lumbar region M43.27 Fusion of spine, lumbosacral region M53.80 Other specified dorsopathies, site unspecified M53.85 Other specified deforming dorsopathies, thoracolumbar region 724.8 724.9 Other symptoms referable to the back Other unspecified back disorders 739.3 Nonallopathic lesions of lumbar region, not elsewhere classified M99.03 Segmental and somatic dysfunction of lumbar region 739.4 Nonallopathic lesions of sacral region, not elsewhere classified M99.04 Segmental and somatic dysfunction of sacral region 756.12 Cogenital spondylolisthesis Q76.2 Congenital spondylolisthesis For a complete list of coding options and descriptions, consult the current ICD-10-CM manual. 31 COOLIEF* Cooled Radiofrequency Systems Pre-Authorization Process: Once a candidate has been identified, medical necessity has been established, and a Waiver of Financial Liability has been signed by the patient, a pre-authorization request may be required by the patient’s insurance carrier. Note: Medicare does not have a pre-authorization process. It is recommended that a potential patient that is covered by Medicare sign an ABN (Advanced Beneficiary Notice). When submitting a pre-authorization request, the following steps should be taken: • Place a call to the payer to verify insurance benefits and determine if a pre-authorization is required. • Provide the payer with the patient’s diagnosis and the appropriate CPT® code • If a pre-authorization is required, documentation to support medical necessity will be required which should be included in the letter of medical necessity (LOMN): • Patient’s brief medical history • Physician’s exam findings • Copies of pertinent reports (MRIs, CT scans, etc) • Alternative treatments previously tried • How the activities of daily life are being impacted by the medical condition • Duration of the diagnosis • Identification of the site of service (office; ASC; or hospital outpatient) Note: Payers base their decisions on medical necessity, as well as benefits, therefore we encourage you to make a strong case for the patient’s particular medical need for the lumbar medial branch neurotomy procedure. 32 COOLIEF* Cooled Radiofrequency Systems COOLIEF* Knee Cooled Radiofrequency COOLIEF* Knee Cooled Radiofrequency is performed to treat the pain associated with chronic knee osteoarthritis (OA) through the use of an internally water-cooled radiofrequency probe to ablate the articular branches of the knee known as genicular nerves. CPT Codes: 64640: Destruction by neurolytic agent, other peripheral nerve or branch COOLIEF* Knee Cooled Radiofrequency is generally performed to ablate the superolateral genicular branch from the vastus lateralis, the superomedial genicular branch from the vastus medialis, and the inferomedial genicular branch from the saphenous nerve. An example of coding commonly used by physicians performing genicular neurotomy is listed below: RF Lesion of superolateral genicular branch from the vastus lateral: 64640 RF Lesion of superomedial genicular branch from the vastus medialis: 64640-59 RF Lesion of inferomedial genicular branch from the saphenous nerve: 64640-59 Services Reporting CPT Modifiers provide additional information about the reported procedure. Many times the specific modifier may reflect actual reimbursement of services. CPT modifier may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be critical to a claim’s status. Optum 360 EncoderPro describes modifiers this way: “A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities.” When reporting COOLIEF* genicular thermal RF ablation services, as outlined in the previously studied protocol, three separate nerves are being ablated during the same intervention. As such, the initial procedure should be reported without modifier. The second procedure, line item 2, can be reported with -59 modifier indicating that the treatment is being delivered to a new site/ organ/nerve. The final procedure, line item 3, can also be reported with -59 modifier indicating that this treatment is also being delivered to a new site/organ/nerve. 33 COOLIEF* Cooled Radiofrequency Systems Device Codes: There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* Probe Kit. The miscellaneous surgical supply code, A4649, can be used to bill for the single-use probe kit, however it is at the payer’s discretion to provide additional reimbursement. 34 COOLIEF* Cooled Radiofrequency Systems ICD-9/ICD-10 Diagnosis Codes: Following is a list of possible diagnosis codes which may support medical necessity for genicular neurotomy to treat the chronic pain caused by these conditions. This list is not intended to be an all-inclusive list. Other ICD-9 diagnostic codes may apply based on the patient’s diagnosis. The physician must always make the final determination of the appropriate diagnosis code. ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 715.16 Osteoarthrosis, localized, primary, lower leg M17.10 Unilateral primary osteoarthritis, unspecified, knee M17.0 Bilateral primary osteoarthritis of knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.5 Other unilateral secondary osteoarthritis of knee M17.2 Bilateral post-tarumatic osteoarthritis of knee M17.30 Unliateral post-traumatic osteoarthritis, unspecified knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other bilateral secondary osteoarthritis of knee M12.561 Traumatic arthropathy, right knee M12.562 Traumatic arthropathy, left knee 715.26 Osteoarthrosis, localized, secondary, lower leg 716.16 Traumatic arthropathy, lower leg 716.66 Unspecified monoarthritis, lower leg 716.86 Other specified arthropathy, lower leg M13.169 M13.161 Monoarthritis, not elsewhere classified, right knee M13.162 Monoarthritis, not elsewhere classified,left knee M12.869 Other specific arthropathies, not elsewhere classified, unspecified knee M07.661 Enteropathic arthropathies, right knee M07.662 Enteropathic arthropathies, left knee M07.669 Enteropathic arthropathies, unspecified knee M12.861 Other specific arthropathies, not elsewhere classified, right knee M12.862 Other specific arthropathies, not elsewhere classified, left knee For a complete list of coding options and descriptions, consult the current ICD-10-CM manual. 35 COOLIEF* Cooled Radiofrequency Systems Pre-Authorization Process: Once a candidate has been identified, medical necessity has been established, and a Waiver of Financial Liability has been signed by the patient, a pre-authorization request may be required by the patient’s insurance carrier. Note: Medicare does not have a pre-authorization process. It is recommended that a potential patient covered by Medicare sign an ABN (Advanced Beneficiary Notice). When submitting a pre-authorization request, the following steps should be taken: • Place a call to the payer to verify insurance benefits and determine if a pre-authorization is required • Provide the payer with the patient’s diagnosis and the appropriate CPT code • If a pre-authorization is required, documentation to support medical necessity will be required which should be included in the letter of medical necessity (LOMN): • Patient’s brief medical history • Physician exam findings • Copies of pertinent reports (MRIs, CT scans, etc.) • Alternative treatments previously tried • How the activities of daily life are being impacted by the medical condition • Duration of diagnosis • Identification of the site of service (office; ASC; or hospital outpatient) Note: Payers base their decisions on medical necessity, as well as benefits, therefore we encourage you to make a strong case for the patient’s particular medical need for genicular neurotomy. 36 COOLIEF* Cooled Radiofrequency Systems Following is a sample letter of medical necessity for the genicular neurotomy procedure to assist you in drafting a pre-authorization request. SAMPLE LETTER OF MEDICAL NECESSITY [Date] [Payer Address] Re: [Insert patient name and subscriber number] Dear [Medical Director] Please consider this letter a request for preauthorization of benefits to treat my patient [insert patient name], who suffers from [insert patient ICD-9 diagnosis code and description of procedure]. It is my clinical judgment that [Mr./Ms. Insert patient last name] is an ideal candidate for genicular neurotomy, and prior to scheduling this procedure I am seeking preauthorization and predetermination of benefits for my patient. Patient History [Mr./Ms. Insert patient last name] presented to me with complaints of [insert detailed patient history with description of patient’s current condition including diagnosis, length of time problem has existed, current/ongoing complaints, and level of impairment. Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life.] Previous treatment efforts include: [indicate procedures, medications, and/or therapies attempted – include outcome of each treatment]. Despite these treatments and therapies, [Mr./Ms. Insert patient last name] has experienced no significant relief from [insert specific symptoms here]. A problem focused history and exam was performed as well as [indicate scans, MRIs, X-rays, etc.]. The findings of these test results confirm my diagnosis of [insert patient diagnosis code] and support my request for treatment. I am recommending a radiofrequency denervation procedure, genicular neurotomy, for the ablation of the articular branches of the knee known as the genicular nerves. The procedure involves the use of the COOLIEF* cooled radiofrequency probes to create targeted lesions at the superolateral genicular branch from the vastus lateralis; the superomedial genicular branch from the vastus medialis; and the inferomedial genicular branch from the saphenous nerve. Because of the varied innervations of these nerves, large radiofrequency lesions are required to ensure complete ablation of each of these three separate nerves. Cooled RF technology allows a large volume of tissue to be heated [without excessively heating the tissue adjacent to the probe tip] compared to conventional radiofrequency electrodes. 37 COOLIEF* Cooled Radiofrequency Systems This procedure will be performed on [indicate anticipated date of procedure] at [indicate site of service and name of facility where the procedure will be performed – physician office, outpatient hospital, ASC]. Please confirm if there are any restrictions on performing this procedure in this setting. Please confirm this procedure will be covered for [insert patient name] based on medical necessity. Please contact me at [insert phone number] if you have any questions. Sincerely, [Doctor Signature] Dr. [Doctor Name] Encl. [relevant diagnostic tests and results, patient’s pertinent medical history records, etc.] 38 COOLIEF* Cooled Radiofrequency Systems Sample Operative Note COOLIEF* KNEE COOLED RADIOFREQUENCY Reference Material Only COOLIEF* KNEE COOLED RADIOFREQUENCY Cooled Genicular RFA PROCEDURE: 1. Superolateral genicular branch from the vastus lateralis 2. Superomedial genicular branch from the vastus medialis 3. Inferomedial genicular branch from the saphenous nerve 4. (Optional) Terminal branch of the nerve vastus intermedius DATE OF PROCEDURE:_________________________________________________________________________ ANESTHESIA: ________________________________________________________________________________ COMPLICATIONS:_____________________________________________________________________________ PROCEDURE IN DETAIL: Hx/PE/meds/allergies/applicable labs reviewed. No changes and no contraindications were found. Full description of the procedure was provided including benefits as well as possible complications including transient increased pain, stomach irritation, mood alteration, transient weakness or parasthesias as well as more serious nerve injury, bleeding, infection or allergic reaction. Informed consent was obtained and documented. The patient was brought to the procedure room and placed on the exam table in a comfortable supine position. The place for needle placement was obtained by manual palpation with radiographic confirmation. The sterile field was prepared by chloroprep and sterile drapes. Local anesthesia superficial and deep was provided by local infiltration of_______________. A 18 gauge 75 mm Halyard Health cooled radiofrequency needle with a 4 mm active tip was placed overlying the Right/left knee joint and using fluoroscopic guidance the needle was advanced to a bony endpoint on the superiolateral portion of the femoral condyle of the Right/left knee. A second needle was advanced to a bony endpoint on the superiomedial portion of the femoral condyle. A third needle was then placed over the inferiomedial portion of the tibial condyle until a bony endpoint was met. Attempted aspiration yielded no blood. Lateral x-‐ray views showed all the needles at 50% depth of the femur and tibia. Motor stimulation was tested ad 2.0 volts with no leg movement. Images were saved in AP and lateral. A mixture consisting of _________ was slowly injected. Then a radiofrequency ablation of each of the geniculate nerves were done at 80 degrees C for 2 minutes and 30 seconds each. The needles were withdrawn. The patient tolerated the procedure well. After observation the patient was discharged with instructions and follow up. They were also provided contact information to call regarding any concerning symptoms or questions. IMPRESSION: 1. Successful geniculate knee radiofrequency ablation was performed. 2. The patient was given prescription of _________________ 3. RTC in ___ week(s). Registered Trademark or Trademark of Halyard Health, Inc. and its affiliates. ©2015 HYH. All rights reserved. www.HalyardHealth.com For more information, call 1-‐800-‐524-‐3577 39 COOLIEF* Cooled Radiofrequency Systems COOLIEF* Hip Cooled Radiofrequency COOLIEF* Hip Cooled Radiofrequency is performed to treat the pain associated with chronic hip joint pain of the hip through the use of an internally water-cooled radiofrequency probe to ablate the femoral and obturator nerves. CPT Codes: There are two coding options when performing hip neurotomy: • 64640: Destruction by neurolytic agent, other peripheral nerve or branch Or • 27299: Unlisted procedure, pelvis or hip joint Obturator and femoral articular sensory branch neurotomy is generally performed to ablate the femoral and obturator nerves. If using CPT code 64640, an example of coding commonly used by physicians is listed below: • RF Lesion of femoral nerve: 64640 • RF Lesion of obturator nerve: 64640-59 • If using the unlisted CPT code 27299, this code would be billed once. • In addition, the physician can bill for fluoroscopic guidance using CPT code 77002-26. Services Reporting CPT Modifiers provide additional information about the reported procedure. Many times the specific modifier may reflect actual reimbursement of services. CPT modifier may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be critical to a claim’s status. Optum 360 EncoderPro describes modifiers this way: “A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities.” When reporting COOLIEF* hip thermal RF ablation services, as outlined in the previously studied protocol, two separate nerves are being ablated during the same intervention. As such, the initial procedure should be reported without modifier. The second procedure, line item 2, can be reported with -59 modifier indicating that the treatment is being delivered to a new site/ organ/nerve. Device Codes: There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* Probe Kit. 40 COOLIEF* Cooled Radiofrequency Systems The miscellaneous surgical supply code, A4649, can be used to bill for the single-use probe kit, however it is at the payer’s discretion to provide additional reimbursement. ICD-9/ICD-10 Diagnosis Codes: Following is a list of possible diagnosis codes which may support medical necessity for hip neurotomy to treat the chronic pain caused by these conditions. This list is not intended to be an all-inclusive list. Other ICD-9 diagnostic codes may apply based on the patient’s diagnosis. The physician must always make the final determination of the appropriate diagnosis code. ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 715.15 Osteoarthrosis, localized, primary, pelvic region and thigh M16.0 Bilateral primary osteoarthritis of hip M16.11 Unilateral primary osteoarthritis, right hip M16.12 Unilateral primary osteoarthritis, left hip M16.7 Other unilateral secondary osteoarthritis of hip M16.2 Bilateral osteoarthritis resulting from hip dysplasia M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4 Bilateral post-traumatic osteoarthritis of hip M16.51 Unilateral post-traumatic osteoarthritis, right hip M16.52 Unilateral post-traumatic osteoarthritis, left hip M16.6 Other bilateral secondary osteoarthritis of hip M12.551 Traumatic arthropathy, right hip M12.552 Traumatic arthropathy, left hip M13.851 Other specified arthritis, right hip 715.25 Osteoarthrosis, localized, secondary, pelvic region and thigh 716.15 Traumatic arthropathy, pelvic region and thigh 716.25 Allergic arthritis, pelvic region and thigh M13.852 Other specified arthritis, left hip 716.55 Unspecified polyarthropathy or polyarthritis, pelvic region and thigh M13.0 Polyarthritis, unspecified 716.65 Unspecified monoarthritis, pelvic region and thigh M13.151 Monoarthritis, not elsewhere classified, right hip M13.152 Monoarthritis, not elsewhere classified, left hip M07.651 Enteropathic arthropathies, right hip M07.652 Enteropathic arthropathies,left hip 716.85 Other specified arthropathy, pelvic region and thigh 41 COOLIEF* Cooled Radiofrequency Systems M12.851 Other specific arthropathies, not elsewhere classified, right hip M12.852 Other specific arthropathies, not elsewhere classified, left hip ICD-9 CODE DESCRIPTION ICD-10 CODE DESCRIPTION 719.45 Pain in joint, pelvic region and thigh M25.551 Pain in right hip M25.552 Pain in left hip 719.65 Other symptoms referable to joint, pelvic region and thigh R29.4 Clicking hip 719.85 Other specified disorders of joint, pelvic region and thigh M25.859 Other specified joint disorders, unspecified hip M25.851 Other specified joint disorders, right hip M25.852 Other specified joint disorders, left hip M70.61 Trochanteric bursitis, right hip M70.62 Trochanteric bursitis, left hip M70.71 Other bursitis of hip, right hip M70.72 Other bursitis of hip, left hip M76.01 Gluteal tendinitis, right hip M76.02 Gluteal tendinitis, left hip M76.11 Psoas tendinitis, right hip M76.12 Psoas tendinitis, left hip M76.21 Iliac crest spur, right hip M76.22 Iliac crest spur, left hip M76.31 Iliotibial band syndrome, right leg M76.32 Iliotibial band syndrome, left leg 726.5 Enthesopathy of hip region For a complete list of coding options and descriptions, consult the current ICD-10-CM manual. 42 COOLIEF* Cooled Radiofrequency Systems Pre-Authorization Process: Once a candidate has been identified, medical necessity has been established, and a Waiver of Financial Liability has been signed by the patient, a pre-authorization request may be required by the patient’s insurance carrier. Note: Medicare does not have a pre-authorization process. It is recommended that a potential patient covered by Medicare sign an ABN (Advanced Beneficiary Notice). When submitting a pre-authorization request, the following steps should be taken: • Place a call to the payer to verify insurance benefits and determine if a pre-authorization is required • Provide the payer with the patient’s diagnosis and the appropriate CPT code • If a pre-authorization is required, documentation to support medical necessity will be required which should be included in the letter of medical necessity (LOMN): • Patient’s brief medical history • Physician exam findings • Copies of pertinent reports (MRIs, CT scans, etc.) • Alternative treatments previously tried • How the activities of daily life are being impacted by the medical condition • Duration of diagnosis • Identification of the site of service (office; ASC; or hospital outpatient) Note: Payers base their decisions on medical necessity, as well as benefits, therefore we encourage you to make a strong case for the patient’s particular medical need for Obturator and Femoral Articular Sensory Branch Neurotomy. Following is a sample letter of medical necessity for the COOLIEF* Hip Cooled Radiofrequency procedure to assist you in drafting a pre-authorization request. SAMPLE LETTER OF MEDICAL NECESSITY [Date] [Payer Address] Re: [Insert patient name and subscriber number] Dear [Medical Director] Please consider this letter a request for preauthorization of benefits to treat my patient [insert patient name], who suffers from [insert patient ICD-9 diagnosis code and description of procedure]. It is my clinical judgment that [Mr./Ms. Insert patient last name] is an ideal candidate for hip neurotomy, and prior to scheduling this procedure I am seeking preauthorization and predetermination of benefits for my patient. 43 COOLIEF* Cooled Radiofrequency Systems Patient History [Mr./Ms. Insert patient last name] presented to me with complaints of [insert detailed patient history with description of patient’s current condition including diagnosis, length of time problem has existed, current/ongoing complaints, and level of impairment. Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life.] Previous treatment efforts include: [indicate procedures, medications, and/or therapies attempted – include outcome of each treatment]. Despite these treatments and therapies, [Mr./Ms. Insert patient last name] has experienced no significant relief from [insert specific symptoms here]. A problem focused history and exam was performed as well as [indicate scans, MRIs, X-rays, etc.]. The findings of these test results confirm my diagnosis of [insert patient diagnosis code] and support my request for treatment. I am recommending a radiofrequency denervation procedure, COOLIEF* Hip Cooled Radiofrequency, for the ablation of the femoral and obturator nerves. The procedure involves the use of the COOLIEF* cooled radiofrequency probes to create targeted lesions at the femoral nerve and the obturator nerve. Because of the varied innervations of these nerves, large radiofrequency lesions are required to ensure complete ablation of each of these two separate nerves. Cooled RF technology allows a large volume of tissue to be heated [without excessively heating the tissue adjacent to the probe tip] compared to conventional radiofrequency electrodes. This procedure will be performed on [indicate anticipated date of procedure] at [indicate site of service and name of facility where the procedure will be performed – physician office, outpatient hospital, ASC]. Please confirm if there are any restrictions on performing this procedure in this setting. Please confirm this procedure will be covered for [insert patient name] based on medical necessity. Please contact me at [insert phone number] if you have any questions. Sincerely, [Doctor Signature] Dr. [Doctor Name] Encl. [relevant diagnostic tests and results, patient’s pertinent medical history records, etc.] 44 COOLIEF* Cooled Radiofrequency Systems Sample Operative Note COOLIEF* HIP COOLED RADIOFREQUENCY PROCEDURE: 1. L/R articular branch of femoral nerve radiofrequency denervation 2. L/R articular branch of obturator nerve radiofrequency denervation COOLIEF* HIP COOLED RADIOFREQUENCY Reference Material Only DATE OF PROCEDURE: ANESTHESIA: COMPLICATIONS: PROCEDURE IN DETAIL: Hx/PE/meds/allergies/applicable labs reviewed. No changes and no contraindications were found. Full description of the procedure was provided including benefits as well as possible complications including transient increased pain, stomach irritation, mood alteration, transient weakness or parathesias as well as more serious nerve injury, bleeding, infection or allergic reaction. Informed consent was obtained and documented The patient was brought to the procedure room and placed on the exam table in a comfortable prone/supine position. The place for the needle placement was obtained by manual palpation with radiographic confirmation. The sterile field was prepared by ___________ and sterile drapes. Local anesthesia superficial and deep was provided by local infiltration of ___ ml _______ % and ___ ml ______%. Using fluoroscopic guidance a 17g 150/100/75mm radiofrequency needle with 4mm active tip was advanced to the anteromedial aspect of the extraarticular portion of the hip joint where the articular branch of the femoral nerve traverses until a bony endpoint is felt. Attempted aspiration yielded no blood. Motor testing was then performed with ___ volts and no lower extremity motor stimulation was observed. __cc of ______% was injected through the RF needle. A thermal radiofrequency lesion of the articular branch of the femoral nerve was then performed at an average maximum tissue temperature greater than 80 degrees C for 2 minutes and 30 seconds. The needle was then withdrawn. A second needle was placed and using fluoroscopic guidance the needle was advanced to the incisura of the acetabulum where the articular branch of the obturator nerve traverses until a bony endpoint was met. Attempted aspiration yielded no blood. Radiographs were made. Motor testing was then performed with ___ volts and no lower extremity motor stimulation was observed. ___cc _______% was injected through the RF needle. A thermal radiofrequency lesion of the articular branch of the obturator nerve was then performed at an average maximum tissue temperature greater than 80 degrees C for 2 minutes and 30 seconds. The needle was then withdrawn. The patient tolerated the procedure well. After observation the patient was discharged with instructions and follow up. They were also provided contact information to call regarding any concerning symptoms or questions. IMPRESSION: 1. Successful cooled radiofrequency ablations of the articular branches of the obturator and femoral nerves was performed. 2. Follow up in ____ weeks to assess the efficacy of the procedure. 3. Estimated Blood Loss: ________ 4. Disposition:_________ Registered Trademark or Trademark of Halyard Health, Inc. and its affiliates. ©2015 HYH. All rights reserved. www.HalyardHealth.com For more information, call 1-800-524-3577 45 COOLIEF* Cooled Radiofrequency Systems Appeals Facilities and physicians may encounter denied, pended, or underpaid claims for numerous reasons. Claims are usually pended or denied for four primary reasons: • Administrative errors made by claims processors • Clerical errors made on claim forms • A determination by the payer that the procedure is not medically necessary • Patient not responding to payer’s request for information Appealing Denied Claims: If a claim is denied, we recommend careful review of the Explanation of Benefits (EOB) for an explanation or reason for the denial. If the EOB does not clearly explain the reason, immediately contact the payer and request an explanation of the denied claim. In those cases where a clerical error was made on the claim form, simply confirm the appropriate codes to use and resubmit a corrected claim form. In other cases, payers may deny claims based on their determination of: • A lack of medical necessity • A diagnosis code does not match with the CPT® code • A determination that the technology is considered investigational In these cases, you should contact the payer and offer to provide additional information about the procedure (COOLIEF* TRANSDISCAL* Disc Biacuplasty Cooled RF, COOLIEF* SINERGY* Sacroiliac Cooled RF, COOLIEF* Thoracic Cooled RF or COOLIEF* Lumbar Cooled RF). You should ask the claims processor to specify what additional materials are required to reverse the original coverage determination. Underpaid Claims: If you feel your claim has been underpaid, contact the claims office identified on the patient’s EOB, and request a review of your claim. Claims may be underpaid for various reasons including: • Low contractual agreement • Incorrect coding of the actual procedure(s) performed • Lack or misuse of appropriate modifier • Lack of supporting documentation Each payer has its own review process, but in most cases, you will be asked to submit your request in writing. Once you determine what the process is, inquire as to where the request should be sent and to whom it should be directed. 46 COOLIEF* Cooled Radiofrequency Systems Claim Reversals: According to a recent Medicare report, the following were listed as the top reasons claims were reversed at the appeal level: • In 45% of the cases reversed, additional information, more detailed documentation of the patient’s condition, or proper diagnosis coding was supplied at the appeal level • In 18% of the cases reversed, a Unique Identification Number (UPIN) was submitted or corrected at the appeal level • In 18% of the cases reversed, a request for modifier change or addition to the claim was requested. To avoid the frustration of claim denials and appeal processing, we suggest checking to be sure that the claim form contains all the required information. Claim submitters should verify that the correct UPIN number, procedure code and diagnosis have been indicated on the claim. Incomplete or insufficient documentation of a patient’s medical condition could result in claim denial. SAMPLE APPEAL LETTER [Date] Attn: [Contact] usually the medical director [Title] [Name of Health Insurance Company] [Address] [City, State, ZIP Code] RE: Denial of [Specify Procedure] procedure [Patient Name] [Policy Number/Group Number/Patient ID#] [Date of Birth] Dear [Name of Contact]: I am writing to appeal, [name of insurance company]’s recent denial of benefits for my patient, [Patient Name] for treatment of [insert diagnosis] utilizing a procedure called [Specify Procedure]. The denial states the procedure is investigational and I strongly dispute those findings. My recommended treatment, [Specify Procedure] has been successfully used in many cases. 47 COOLIEF* Cooled Radiofrequency Systems [Patient Name] has been thoroughly evaluated and has been diagnosed with [insert diagnosis]. Enclosed with this letter is the original documentation submitted and I request that you review the information again with particular attention to the patient’s history of [insert diagnosis] which has been ongoing since [include date of onset]. Numerous conservative attempts at treatment have been tried and failed, such as [include medical history, treatments tried, include conservative treatments and length of time]. Despite these attempts, [Patient Name] has received no relief from symptoms and is currently [describe patient’s current condition and how activities of daily life are affected]. I have included the results of tests which indicate [list findings from CT, MRI, etc., and any other tests performed to confirm diagnosis]. Based on these findings and our previous attempts at conservative treatments, I believe it is medically necessary to move forward and schedule [Patient Name] for this procedure. I firmly believe that [Patient Name] is an excellent candidate for [Specify Procedure]. I request your immediate reconsideration of coverage for this procedure. Thank you for your attention to this matter, and I look forward to your response. Please contact me if you have additional questions. Sincerely, [Physician’s Name] [Physician’s Practice Name] 48 For more information, please visit: www.halyardhealth.com Call 1-844-HALYARD (1-844-425-9273) in the United States and Canada. Customer-centric solutions include the tools, resources and support to help you provide the best in patient care. Knowledge Network* Accredited Education In-Service Training and Technical Support Credentialed Sales Representatives Tools & Best Practices Clinical Research Commitment to Excellence CPT® is a Registered Trademark of the American Medical Association. All rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained in this guide. The AMA assumes no responsibility for consequences attributable to or related to any use or interpretation of any information or views contained or not contained in this guide. www.halyardhealth.com *Registered Trademark or Trademark of Halyard Health, Inc. or its affiliates. © 2015 HYH. All rights reserved. *Registered Trademark or Trademark of Halyard Health, Inc. or its affiliates. © 2014 HYH. All rights reserved. CP141 C15949
