CPT 64635, 64636, 64633 – Paravertebral Facet Joint code

    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.

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.

OXFORD insurance guidelines

This policy applies to Oxford Commercial plan membership.

Benefit Type General Benefits Package

Referral Required (Does not apply to non-gatekeeper products)

Yes – Office

Authorization Required (Precertification always required for inpatient admission)

Yes1,2 – Outpatient Precertification with Medical Director Review Required Yes1,2,3

Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Office2,3

– Outpatient

Special Considerations 1Precertification requests for any of the CPT codes listed in the Applicable Codes section of this policy require review by a Medical Director or their designee when provided in an outpatient facility setting. 2CPT codes 64633 and 64635 require review by a Medical Director or their designee regardless of the site of service.

3Precertification is required under the Member’s General Benefits package for CPT codes 64633 and 64635 when performed in the office of a participating provider. For Commercial plans, precertification is not required, but is encouraged for out-of-network services performed in the office that are covered under the Member’s General Benefits package. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered.

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable.

This guideline applies to participating providers located in Connecticut (CT) and New York (NY) that are providing services to members enrolled on Oxford commercial products.

Note: This policy does not apply to participating providers located in New Jersey (NJ).

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage.

Neurologic

64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

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

57460 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix

ICD-10 Codes that Support Medical Necessity