LCD Requirements - Facet Joint 64490 - 64495; 64633-64636

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Posts: 59
Joined: Wed Mar 13, 2013 9:04 am

Tue Aug 21, 2018 10:33 am

Based on the Palmetto facet joint injections LCD L36471, when billing for radiofrequency neurotomy (RFA), if the 3 month history of pain is not documented for the previous two diagnostic medial branch blocks, is the RFA non billable (the two diagnositic MBBs were performed within the 3 month history of pain requirement)?

Please see example below:
2/7/2017 - First documentation of significant cervical pain reported by patient
4/18/2017 - 1st MBB (3 month history of pain not met)
5/2/2017 - 2nd MBB (3 month history of pain not met)
5/25/2017 - RFA performed (3 month history of pain documented on 2/7/2017) - Is this supported/billable?

Please send reference to support. Thank you.
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Posts: 431
Joined: Mon Apr 09, 2012 1:54 pm

Wed Aug 29, 2018 9:03 am

Thermal Medial Branch Radiofrequency Neurotomy (includes RF and microwave technologies):

· Facet joint denervation with RF medial branch neurotomy may be considered only when dual MBBs provide significant relief of the primary or index pain and duration of relief is consistent with the agent employed (see notation above regarding therapeutic blocks).

· Repeat denervation procedures involving the same joint will only be considered medically necessary if the patient experienced ≥ 50% improvement of pain and improvement in patient specific ADLs that are documented for at least 6 months.

The LCD requirements for the RF are met based on the information sent in the question. Of note, the example states “The first documentation of cervical pain…” Is this truly the first date the patient had the pain, or is this the date the patient first saw a provider about it? The LCD requirements are related to how long the patient has been experiencing the pain as opposed to how long it has been documented in a provider note, so it is possible the 3 months requirement was actually met for the MBBs.

Your question has been answered by Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA
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