Fluoroscopy and RF Lesioning Code

Date of Service Guides Approval of 27096 with Fluoro

Question: Some of your payers deny 77003 when you bill it with SI joint injections in the same session. You realize the fluoroscopy is not any more payable with facet joint injections, however shouldn't you get paid for the SI joint injection?

Answer: Your first step in deciding whether you can bill the fluoroscopy and sacroiliac (SI) joint injection separately is certainly to check the date of service.

Effective Jan. 1, 2012, fluoroscopy is included with the SI joint injection, thus you can't bill for both procedures in the same patient encounter. Instead, you'll only bill medical billing code 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed). As the descriptor now states "with image guidance," you must not also report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, or subarachnoid]). CPT® comprises the parenthetical note "Do not report 77003 in conjunction with medical billing code 27096…" specifying that fluoroscopic guidance used in performance of a SI joint injection is not separately billable. Furthermore, it would not be compliant coding to append modifier 59 (Distinct procedural service) to 77003 to evade the NCCI edits, in case the fluoroscopy was only used with the SI joint injection.

Choosing the Accurate RF Lesioning Code

Question: How do you code radiofrequency lesioning of the greater occipital nerve?

Answer: Review your physician's procedure documentation, as the accurate choice hinges on the mode of radiofrequency (RF) used to create the nerve lesion(s).

While she uses continuous RF to do away with the greater occipital nerve, report 64640 (Destruction by neurolytic agent; other peripheral nerve or branch). In case she uses pulsed RF, though, CPT® directs you to medical billing code 64999 (Unlisted procedure, nervous system).

Explanation: Continuous (a.k.a. standard or thermal) RF therapy uses continuous radio wave energy to heat up nerve tissue to a point that it creates a destruction of the target nerve. This neurolytic lesioning reduces the patient's pain by interrupting the sensory nerve pathways.

On the other hand, pulsed RF therapy uses shorter continuous bursts of radio wave energy at much lower temperatures. Pulsed RF is not considered to be destructive; the technique "stuns" the target nerve tissue to stop it from transmitting pain signals rather than directly damaging the target nerve tissue.

Heads up: Certain payers now look at the provider's documentation for the temperature related to the RF. For instance, United Healthcare's coverage policy for Ablative Treatment for Spinal pain contains the requirements of "temperature 60 degrees Celsius or more and duration of ablation 40-90 seconds." Providers who cover this type of information in their documentation make correct medical coding and billing easier.