Sunday, September 25, 2016

CPT 64635, 64636, 64633 - Paravertebral Facet Joint code


CPT NEW DESCRIPTION 

64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT


64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64635  New code  Destruction by neurolytic agent paravertebral facet joint nerve(s) (fluoroscopy or CT; Lumbar or sacral, single facet joint

(For bilateral procedure, report 64635 with modifier 50)


64636 New code   Lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)



Paravertebral Facet Joint Denervation

1. If a provider denervates only one level, unilateral or bilateral, CPT codes 64633 or 64635 should be used. If the denervation is performed at more than one level, unilateral or bilateral, CPT codes 64634 and 64636 should be used for each of the subsequent levels. If denervation is performed bilaterally, Modifier 50 should be appended to the procedure code with number of services of one.

2. Use the appropriate CPT code in Item 24D on the CMS-1500 form (or electronic equivalent) and link it to the applicable ICD-9-CM code in Item 24E (or electronic equivalent).

3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636.

Revision History Number/Explanation 01/01/2012 CPT 2012 code update deleted codes 64622, 64623, 64626 and 64627, added new codes 64633, 64634, 64635, and 64636 removed codes 77003, 77012 and references to them.

08/01/2011 correction to Paravertebral Facet Joint Denervation number 3. Fluoroscopic guidance and localization for needle placement, is not included in codes 64622 64627 effective 03/18/2010.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 64633, 64634, 64635, 64636

Facet Joint Denervation

Specialty Matched Consultant Advisory Panel review 11/30/2011. “Description” section revised. “Chemical denervation” added to the “When Not Covered” section. “All other techniques of facet joint denervation for the treatment of chronic back pain are considered investigational including, but not limited to: Pulsed radiofrequency denervation; Laser; Cryodenervation; and Chemical denervation.” “Therapeutic (as opposed to diagnostic) medial branch blocks are considered investigational.” “Policy Guidelines” updated. Added the following new 2012 CPT codes to the “Billing/Coding” section: 64633, 64634, 64635, and 64636. Deleted CPT codes: 64622, 64623, 64626, and 64627.

Introduction:

This policy does not address sacral conditions or injections or neurotomies. Sacral injections, identified on the claim by the ICD-10 codes M43.27, M43.28, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, are not subject to the requirements of this LCD.

Facet joints are paired diarthrodial articulations of the superior and inferior articular processes of adjacent vertebrae. The medial branches (MB) of the dorsal rami of the segmental nerves innervate facet joints and the MB nerves from the two adjacent dorsal rami innervate each joint. (Exceptions to this rule are the C2-3 facet joint, which is innervated by the third occipital nerve; and the L5-S1 facet joint, which is innervated by the L4 MB and the L5 dorsal ramus.)

Facet joint injection techniques are used in the diagnosis and/or treatment of chronic neck and back pain. However, the evidence of clinical efficacy and utility has not been well-established in the medical literature, which is replete with non-comparable and inadequately designed studies. Further, there is a singular dearth of long-term outcomes reports. This is particularly problematic given the steroid dosages administered. These drugs alone may develop the relief experienced by patients but are associated with serious adverse health events and could as well be administered orally. Hence, ongoing coverage requires outcomes reporting as described in this LCD to allow future analysis of clinical efficacy.

Definitions

A zygapophyseal (aka facet) joint “level” refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint.

A “session” is defined as all injections/blocks/RF procedures performed on one day and includes medial branch blocks (MBB), intraarticular injections (IA), facet cyst ruptures, and radiofrequency (RF) ablations.

A “region” is all injections performed in cervical/thoracic or all injections performed in lumbar (not sacral) spinal areas.

"Diagnosis” of facet-mediated pain requires the establishment of pain relief following medial branch blocks (MBB) or intra-articular injections (IA). Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish the facet joint as the pain source.

Indications 

Patient must have history of at least 3 months of moderate to severe pain with functional impairment and pain is inadequately responsive to conservative care such as NSAIDs, acetaminophen, physical therapy (as tolerated).

Pain is predominantly axial and, with the possible exception of facet joint cysts, not associated with radiculopathy or neurogenic claudication.

There is no non-facet pathology that could explain the source of the patient’s pain, such as fracture, tumor, infection, or significant deformity.

Clinical assessment implicates the facet joint as the putative source of pain.

General Procedure Requirements: 

Pre-procedural documentation must include a complete initial evaluation including history and an appropriately focused musculoskeletal and neurological physical examination. There should be a summary of pertinent diagnostic tests or procedures justifying the possible presence of facet joint pain.

A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, nerves injected and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre and post-procedural pain assessments. With RF neurotomy, electrode position, cannula size, lesion parameters, and electrical stimulation parameters and findings must be specified and documented.

Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be reimbursed.

A hard (plain radiograph with conventional film or specialized paper) or digital copy image or images which adequately document the needle position and contrast medium flow (excluding RF ablations and those cases in which using contrast is contra-indicated, such as patients with documented contrast allergies), must be retained and submitted if requested.

In order to maintain target specificity, total IA injection volume must not exceed 1.0 mL per cervical joint or 2 mL per lumbar joint, including contrast. Larger volumes may be used only when performing a purposeful facet cyst rupture in the lumbar spine.

Total MBB anesthetic volume shall be limited to a maximum of 0.5 mL per MB nerve for diagnostic purposes and 2ml for therapeutic. For a third occipital nerve block, up to 1.0 mL is allowed for diagnostic and 2ml for therapeutic purposes.

In total, no more than 100 mg of triamcinolone or methylprednisolone or 15 mg of betamethasone or dexamethasone or equivalents shall be injected during any single injection session.

Both diagnostic and therapeutic IA facet joint injections and medial branch blocks (see criteria below) may be acceptably performed without steroids.


Paravertebral Facet Joint Denervation

1. If a provider denervates only one level, unilateral or bilateral, CPT codes 64633 or 64635 should be used. If the denervation is performed at more than one level, unilateral or bilateral, CPT codes 64634 and 64636 should be used for each of the subsequent levels. If denervation is performed bilaterally, Modifier 50 should be appended to the procedure code with number of services of one.

2. Use the appropriate CPT code in Item 24D on the CMS-1500 form (or electronic equivalent) and link it to the applicable ICD-9-CM code in Item 24E (or electronic equivalent).

3. Fluoroscopic and CT guidance and localization for needle placement, is included in codes 64633- 64636.

Revision History Number/Explanation


01/01/2012 CPT 2012 code update deleted codes 64622, 64623, 64626 and 64627, added new codes 64633, 64634, 64635, and 64636 removed codes 77003, 77012 and references to them. 08/01/2011 correction to Paravertebral Facet Joint Denervation number 3. Fluoroscopic guidance and localization for needle placement, is not included in codes 64622-64627 effective 03/18/2010.

Coverage Indications, Limitations, 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.

    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).

    Indications

    The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will be considered to be medically reasonable and necessary as follows:

    • The paravertebral facet joint(s) have been identified as the source of the patient’s pain by undergoing a diagnostic paravertebral facet joint (median branch) block. Temporary or prolonged abolition of the pain suggests that the facet joint (s) 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) destruction is performed by appropriately trained providers.

    The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that “reasonable and necessary" services are "ordered and/or furnished by qualified personnel."

    A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

    Limitations

    The destruction of cervical, thoracic or lumbar paravertebral facet joint (median branch) nerves will not be considered medically reasonable and necessary when:

    • Performed without fluoroscopic guidance. A mandatory requirement of paravertebral facet joint (median branch) destruction is the use of fluoroscopic guidance to confirm the proper positioning of the needle electrode. Failure to use fluoroscopic guidance will result in the services receiving a denial; or

    • The medical records do not support that the patient experienced temporary or prolonged abolition of the pain after a facet joint nerve block injection; or

    • The medical records do not demonstrate that destruction was performed at the median branch of the spinal nerve innervating the facet joint.


Group 1 Codes

64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT

64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT

64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)



Minimally Invasive & Laser Spine Procedures 

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Prior authorization is required for:

1. Laser facet ablation / denervation /rhizotomy (64633, 64634, 64635, 64636)
2. Intradiscal steroid injection
3. Epidurolysis / percutaneous adhesiolysis (when coded with 64640)
4. Minimally invasive lumbar decompression – “MILD” procedure. (0274T, 0275T) Prior authorization is not required for microdisectomy, also known as percutaneous manual nucleotomy.

Prior authorization is not applicable for some procedures because these services are considered investigational/experimental. Please see the “Procedures that are not covered” section for details. The provider and facility will be liable for payment unless:

1. The provider notifies the member that a specific service has been determined by HealthPartners to be investigational/experimental; and

2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered; and

3. The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment. Coverage

Minimally invasive back procedures are considered investigational/experimental and therefore not covered. Coverage and non-coverage is listed below.

Procedures that are covered

1. Microdiscectomy, also known as percutaneous manual nucleotomy Procedures that are not covered

The following procedures are considered investigative and not covered because the scientific evidence, to date, does not permit a conclusion to be reached regarding their efficacy.

1. Laser spine procedures, including but not limited to:
A. Laser discectomy, also known as laser-assisted discectomy, laser disc decompression or laser-assisted disc decompression (62287)
B. Percutaneous laser discectomy (62287)
C. Laparoscopic laser discectomy
D. Endoscopic laser foraminoplasty
E. Endoscopic laser foraminotomy
F. Endoscopic laser laminotomy
G. Laser laminectomy
H. Laser facet ablation / denervation /rhizotomy (64633, 64634, 64635, 64636) Clinical studies have not shown a clinically significant benefit of use of laser over any other method of tissue resection in spinal surgery. No additional benefit will be provided for the use of a laser in spinal surgery.
2. APLD (Automated percutaneous lumbar discectomy) (62287)
3. Intradiscal electrothermal therapy ( IDET) (22526, 22527)
4. Nucleoplasty (e.g., SpineWand™ coblation therapy)
5. Transdiscal biacuplasty, aka cooled radiofrequency ablation (RFA) (22526, 22527)
6. Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) (22526, 22527)
7. Intradiscal steroid injection (62290, 62291, 62292, 0213T- 0218T)
8. X-close
9. Minimally invasive lumbar decompression – “MILD” procedure. (0274T, 0275T)
10. Epidurolysis / percutaneous epidural Adhesiolysis (62263, 62264, 64640)

64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance
(fluoroscopy or CT); lumbar or sacral, single facet joint

A patient undergoes a radiofrequency nerve destruction of two medial branch nerves L3 and L4 innervating the symptomatic lumbar facet joint. Reimbursement consideration is based upon the following code selection:

* 64635 — $516.47 (approximate 2012 ASC reimbursement) Coding tips:

* Image guidance and localization are required for the performance of paravertebral facet joint nerve destruction by neurolytic agent described by 64633-64636.

* Do not report 64633-64636 in conjunction with 77003 or 77012). Both CPT 77003 and/or 77012 are considered inclusive to the injection procedure in 2012. Note: If CT or fluoroscopic imaging is not used/documented, report unlisted CPT code 64999.

* If both facet joints at the same vertebral level are treated, then CPT 64633 or 64635 should be reported with modifier -50 appended pending carrier reporting requirements for bilateral procedures (-50 versus RT/LT versus units).

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 64633, 64634, 64635, 64636

***Note: The American Medical Association’s CPT Editorial Panel decided in June 2005 that the unlisted CPT code 64999 should be used for pulsed RF treatment as opposed to other specific codes.


Use code 64633 for the Destruction of Paravertebral Facet Joint Nerve(s) by neurolytic agent with Fluoro. or CT image guidance; Cervical or Thoracic, single facet joint for the 1st level performed.

Use Add-on Code for additional levels is code 64634.

Use code 64635 for the Destruction of Paravertebral Facet Joint Nerve(s) by neurolytic agent with Fluoro. or CT image guidance; Lumbar or Sacral, single facet joint for the 1st level performed.

Use Add-on Code for additional levels is code 64636.

Code Rhizotomy procedures from the Destruction by Neurolytic Agent codes.


Facet Joint Denervation

Added the following new 2012 CPT codes to the “Billing/Coding” section: 64633, 64634, 64635, and 64636. Deleted CPT codes: 64622, 64623, 64626, and 64627. Notification given 1/1/2012. Policy effective date 4/1/2012. (btw)

1/24/12 Added new 2012 CPT codes, 64633, 64634, 64635, and 64636 to Billing/Coding section. Removed the following deleted codes, 64622, 64623, 64626, and 64627. Also removed 77003 since this service is now reported as part of the new procedure codes. (btw)

Using with Modifier 


Modifier -50

**To bill for identical bilateral procedures where there is not an all-inclusive code, bill the procedure code with a “50” modifier on one line indicating one unit of service.

** The soft ware will identify the same code billed twice for the same date of service; where the historical code has been appended with the bilateral -50 modifier and denies the second submission of the procedure code, regardless if the 50 modifier is present. Providers will no longer be able to bill for bilateral procedures on two lines with/without the modifier -50, or on one line with a count of two.

Example: CPT 69436 billed with a 50 modifier on a single date of service. CPT code billed a second time for the same date of service without the modifier 50.

CODE DESCRIPTION

 69436-50 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA
 69436 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA

Explanation:

• Procedure code 69436 was performed bilaterally and submitted once with the modifi er -50.
• The second submission of procedure code 69436 with or without modifier 50 is not recommended for separate reporting,
 because the procedure code was previously billed once on the same date of service with the modifier -50.



Bilateral Procedures: Billing Clarification

When billing for bilateral procedures performed during the same session (unless otherwise directed in CPT), providers are to use the -50 modifier (Bilateral procedure) with the appropriate CPT code and place a “1” in the units field of the claim form. The site specific modifiers ‘LT’ (Left side) or ‘RT’ (Right side) may be used on appropriate CPT codes only when services are performed on either the right OR the left side.


Providers should not use the ‘LT’ and ‘RT’ modifier on the same procedure code instead of the -50 modifier. For example, during the same session it is not appropriate to use the ‘RT’ and ‘LT’ on CPT procedure code 69436 (Tympanostomy…) when performed bilaterally.

ICD-10 Codes that Support Medical Necessity


M47.011Anterior spinal artery compression syndromes, occipito-atlanto-axial region
M47.012Anterior spinal artery compression syndromes, cervical region
M47.013Anterior spinal artery compression syndromes, cervicothoracic region
M47.014Anterior spinal artery compression syndromes, thoracic region
M47.015Anterior spinal artery compression syndromes, thoracolumbar region
M47.016Anterior spinal artery compression syndromes, lumbar region
M47.019Anterior spinal artery compression syndromes, site unspecified
M47.021Vertebral artery compression syndromes, occipito-atlanto-axial region
M47.022Vertebral artery compression syndromes, cervical region
M47.029Vertebral artery compression syndromes, site unspecified
M47.11Other spondylosis with myelopathy, occipito-atlanto-axial region
M47.12Other spondylosis with myelopathy, cervical region
M47.13Other spondylosis with myelopathy, cervicothoracic region
M47.14Other spondylosis with myelopathy, thoracic region
M47.16Other spondylosis with myelopathy, lumbar region
M47.21Other spondylosis with radiculopathy, occipito-atlanto-axial region
M47.22Other spondylosis with radiculopathy, cervical region
M47.23Other spondylosis with radiculopathy, cervicothoracic region
M47.24Other spondylosis with radiculopathy, thoracic region
M47.25Other spondylosis with radiculopathy, thoracolumbar region
M47.26Other spondylosis with radiculopathy, lumbar region
M47.27Other spondylosis with radiculopathy, lumbosacral region
M47.28Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M47.811Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region
M47.812Spondylosis without myelopathy or radiculopathy, cervical region
M47.813Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M47.814Spondylosis without myelopathy or radiculopathy, thoracic region
M47.815Spondylosis without myelopathy or radiculopathy, thoracolumbar region
M47.816Spondylosis without myelopathy or radiculopathy, lumbar region
M47.817Spondylosis without myelopathy or radiculopathy, lumbosacral region
M47.818Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region
M47.891Other spondylosis, occipito-atlanto-axial region
M47.892Other spondylosis, cervical region
M47.893Other spondylosis, cervicothoracic region
M47.894Other spondylosis, thoracic region
M47.895Other spondylosis, thoracolumbar region
M47.896Other spondylosis, lumbar region
M47.897Other spondylosis, lumbosacral region
M47.898Other spondylosis, sacral and sacrococcygeal region
M54.2Cervicalgia
M54.30Sciatica, unspecified side
M54.31Sciatica, right side
M54.32Sciatica, left side
M54.5Low back pain
M54.6Pain in thoracic spine
M96.1Postlaminectomy syndrome, not elsewhere classified

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