coolief* cooled radiofrequency reimbursement guide

COOLIEF* COOLED RADIOFREQUENCYREIMBURSEMENT GUIDE

COOLIEF*Cooled Radiofrequency Systems

Revised 10/2016

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HALYARD* Pain Management Cooled RF Systems Reimbursement Guide

Table of Contents

• Introduction .......................................................................................................................... 2

• Reimbursement Hotline ..................................................................................................... 3

• COOLIEF* TRANSDICAL* Disc Biacuplasty Cooled Radiofrequency ....................... 3

• COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency ........................................... 9

• COOLIEF* Cervical Cooled Radiofrequency ............................................................... 18

• COOLIEF* Thoracic Cooled Radiofrequency ..............................................................26

• COOLIEF* Lumbar Cooled Radiofrequency ................................................................33

• COOLIEF* Knee Cooled Radiofrequency .....................................................................38

• COOLIEF* Hip Cooled Radiofrequency ........................................................................45

• Appeals ................................................................................................................................. 51

• Appendix ..............................................................................................................................54

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.

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Reimbursement HotlineTo assist your office or facility, Halyard Health provides experienced reimbursement assistance

for Coolief Cooled RF procedures through our consultant, The Reimbursement Group

(TRG). TRG provides physicians and hospital business staff with guidance to streamline the

reimbursement process. The staff at TRG is experienced in working with URAC Standards and

Patient Protection and Affordable Care Act criteria.

TRG’s certified medical coders, auditors, and nurse case managers are provided by Halyard to

assist with your reimbursement needs, including:

• Filing pre-authorization requests for benefits on behalf of your patients

• Answers to questions related to CPT and ICD-10 codes

• Patient eligibility and benefits verification

• Assistance with filing pre-service appeals and claim denials

• Claim submission guidance

• Peer-to-peer support

Reimbursement specialists are available Monday through Friday from 8:00 am to 8:00 pm EST.

TRG can be reached at:

Phone: 1-855-779-6000

Fax: 224-433-5144

Email: [email protected]

Note: TRG is HIPAA compliant and can promptly answer your questions and begin working

directly with your insurance carriers for your Coolief patients.

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

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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.

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

DESCRIPTIONICD-10 CODE

DESCRIPTION

722.52Degeneration of lumbar or lumbosacral intervertebarl disc

M51.36Other intervertebral disc degeneration,lumbar region

M51.37Other intervertebral disc degeneration,lumbosacral region

722.6Degeneration of intervertebral disc, site uinspecified

M51.36Other intervertebral disc degeneration,lumbar region

M51.37Other intervertebral disc degeneration,lumbosacral region

722.93Other and unspecified disc disorder of lumbar region

M46.47 Discitis, unspecified, lumbosacral region

M51.86Other intervertebral disc disorders, lumbar region

M51.87Other intervertebral disc disorders, lumbosacral region

M46.46 Discitis, unspecified, lumbar region

724.2 Lumbago M54.5 Low back pain

724.8 Other symptoms referable to the back M54.08Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region

M54.06Panniculitis affecting regions of neck and back, lumbar region

M54.07Panniculitis affecting regions of neck and back, lumbosacral region

M54.09Panniculitis affecting regions of neck and back,multiple sites in spine region

724.9 Other unspecified back disorders M43.26 Fusion of spine,lumbar region

M43.27 Fusion of spine,lumbosacral region

739.3Nonallopathic lesions of lumbar region, not elsewhere classified

M99.03Segmental and somatic dysfuntion of lumbar region

For a complete list of coding options and descriptions, consult the current ICD-10-CM manual.

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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.

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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.

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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.)

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Sample Operative Note TRANSDISCAL RADIOFREQUENCY

Reference Material Only

TRANSDISCAL RADIOFREQUENCY PATIENT: MRN: PREOPERATIVE DIAGNOSIS: POSTOPERATIVE DIAGNOSIS: PROCEDURE: Radiofrequency ablation of the posterior and lateral annulus fibrosus DATE OF PROCEDURE: ANESTHESIA: COMPLICATIONS: CONSENT: A full description of the procedure was provided including benefits as well as possible complications. All questions were answered and informed consent was given and signed. ASA guidelines for fasting were verified prior to sedation.

PROCEDURE IN DETAIL The patient was brought into the procedure room and placed on the exam table in a comfortable prone position. A grounding pad was placed on the LEFT/RIGHT thigh. The lumbar spine was widely prepped with a chloraprep solution, allowed to air dry and draped in standard sterile surgical fashion. Local anesthesia was provided by ____mL of ___ % __________ delivered with a 25g needle. Using intermittent fluoroscopy, a 17g 150mm radiofrequency introducer needle was placed at the planned anatomical targets with a perpendicular, extrapedicular approach inserting into the posterior annulus fibrosus. A second 17g 150mm introducer was placed contralateral to the first. The stylets were removed and two radiofrequency probes with 6mm active tips were inserted while ensuring the probes were extending from the introducers into the posterior annulus fibrosus. Needle tip positon of the probes were verified in the AP and lateral views. Radiofrequency energy was then delivered between the two probes in the annulus fibrosus at 50 degrees Celsius for 15 minutes. Tissue impedances were noted to be between 125-250 Ohms. A 2nd lesion on both the left and right side was performed at 80 degrees Celsius for 2 minutes and 30 seconds to cover the lateral border of the annulus without movement of the introducers/probes. POST PROCEDURE EVALUATION: The patient tolerated the procedure well. After observation the patient was discharged with instructions and follow up. The patient was also provided contact information to call regarding any concerning symptoms or questions. IMPRESSION: 1. Successful transdiscal radiofrequency ablation was performed without complication. 2. RTC in ___ week(s). 3. Estimated Blood Loss: ______ 4. Fluoroscopy time: ______ seconds

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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



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 non-

thermal 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.”

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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.

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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

353.1 Lumbosacral plexus lesions G54.1 Lumbosacral plexus disorders

353.4Lumbosacral root lesions, not elsewhere classified

G54.4Lumbosacral root disorders, not elsewhere classified

353.8 Other nerve root and plexus disorder G54.8 Other nerve root and plexus disorders

G55Nerve root and plexus compressions in diseases classified elsewhere

719.45 Pain in joint, pelvic region and thigh M25.551 Pain in right hip

M25.552 Pain in left hip

720.O Ankylosing spondylitis M45.0Ankylosing spondylitis of multiple sites in spine

M45.7Ankylosing spondylitis of lumbosacral region

M45.8Ankylosing spondylitis sacral and sacrococcygeal region

M48.8X7Other specified spondylopathies lumbosacral region

M48.8X8Other specified spondylopathies sacral and sacrococcygeal region

720.2 Sacroilitis M46.1 Sacroiliitis, not elsewhere classified

721.3Lumbosacral spondylosis without myelopathy

M47.817Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.26Other spondylosis with radiculopathy, lumbar region

M47.27Other spondylosis with radiculopathy, lumbosacral region

M47.816Spondylosis without myelopathy or radiculopathy, lumbar region

M47.896 Other spondylosis, lumbar region

M47.897 Other spondylosis, lumbosacral region


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

724.6 Disorders of the sacrum M43.27 Fusion of spine, lumbosacral region

M43.28Fusion of spine, sacral and sacrococcygeal region

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ICD-9 CODE


DESCRIPTION

M53.2X7 Spinal instabilities, lumbosacral region

M53.2X8Spinal instabilities, sacral and sacrococcygeal region

M53.86 Other specified dorsopathies, lumbar region

M53.87Other specified dorsopathies, lumbosacral region

M53.88Other specified dorsopathies, sacral and sacrococcygeal region

724.8 Other symptoms referable to the back M54.08Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region


M54.17 Radiculopathy, lumbosacral region

739.4Nonallopathic lesions of sacral region, not elsewhere classified

M99.04Segmental and somatic dysfunction of sacral region

M99.05Segmental and somatic dysfunction of pelvic region

756.12 Cogenital spondylolisthesis Q76.2 Congenital spondylolisthesis


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submitted to the patient’s insurance carrier prior to performing the COOLIEF* SINERGY*

Sacroiliac Cooled RF Treatment.


patient that is covered by Medicare sign an ABN (Advanced Beneficiary Notice).



required.



required which should be included in the letter of medical necessity (LOMN):







• 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.

14


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.


[Date]


[Title]


[Address]


RE: Treatment authorization request for [Patient Name]


[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.

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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,



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.

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Sample Operative Note

SINERGY SACROILIAC RADIOFREQUENCY


SINERGY SACROILIAC RADIOFREQUENCY

PROCEDURE: MRN: PREOPERATIVE DIAGNOSIS: POSTOPERATIVE DIAGNOSIS: PROCEDURE: 1. Radiofrequency Ablation of LT/RT L5 Dorsal Ramus and LT/RT L4 medial branch 2. Sacroiliac Joint Ablation - Lateral Branches of LT/RT S1, S2, S3

DATE OF PROCEDURE: ANESTHESIA: MAC, Conscious Sedation, None COMPLICATIONS: None CONSENT: A full description of the procedure was provided including benefits as well as possible complications. All questions were answered and informed consent was given and signed. ASA guidelines for fasting were verified prior to sedation. PROCEDURE IN DETAIL The patient was brought into the fluoroscopy suite and carefully assisted into the prone position on the fluoroscopy table and allowed to adjust to a position of comfort. A grounding pad was placed on the LEFT/RIGHT thigh. The low back and buttocks were widely prepped with a chloraprep solution, allowed to air dry and draped in standard sterile surgical fashion. Local anesthesia was provided by ____mL of ___ % __________ delivered with a 25 g needle. PROCEDURE #1: Radiofrequency Ablation of Dorsal Ramus of L5, medial branch of L4. A 17g 75/100/150mm radiofrequency introducer needle was placed to the planned anatomic target, guided with intermittent fluoroscopy with a perpendicular approach, to terminally place at the LEFT/RIGHT sacral ala and the superior articular process at the transverse process for the LEFT/RIGHT L4 medial branch nerve. The stylets were removed and the radiofrequency probes with a 4mm active tip were then inserted. Needle tip position of the probes were verified in the AP, oblique, and lateral views. At each site, the medial branch nerve was stimulated at 2Hz to a maximum of 1-2volts determined to finalize safe needle and electrode placement. The patient was awake and responsive during this portion of the procedure. Each target was anesthetized with 1-2mL of ____% ________ anesthesia for lesioning and then each target was lesioned at 80 degrees Celsius for 2 minutes and 30 seconds. Tissue impedences were noted to be between 250 and 500 Ohms. PROCEDURE #2: Radiofrequency Ablation of S1, S2, S3 Lateral Branches Using the AP fluoroscopic view for visualization of the lateral PSFA as defined by the pre-placed 27-gauge Quincke needles, appropriate skin starting positions were defined. Using the PSFA as a “clock-face”, the positions were: S1; Right = 1 o’clock, 3 o’clock and 5 o’clock S2; Right = 1 o’clock, 3 o’clock and 5 o’clock S3; Right = 1 o’clock, 5 o’clock

17


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2

Using fluoroscopic guidance, a 17g introducer needle was inserted sequentially onto the target positions described above until the introducer tip touched the bony surface of the sacrum. The stylet was withdrawn from the introducer and the radiofrequency probe with a 4 mm active tip was fully inserted into the introducer. A lateral view was obtained for standard reference. At each of the targets, needle placement was verified with the use of multi-planar fluoroscopy. The needle tip position was approximately 7 - 10mm lateral to the PSFA as determined by using an Epsilon ruler. At each site, the lateral branch nerve was stimulated at 2 Hz to a maximum of 1-2 volts determined to finalize safe needle and electrode placement. The patient was awake and responsive during this portion of the procedure. Each target was anesthetized with 1-2 mL of ___% __________ anesthesia for lesioning and then each target was lesioned at 80 degrees Celsius for 2 minutes and 30 seconds. Tissue impedences were noted to be between 250- 500 Ohms. At the conclusion of the lesioning the needles were removed and bandages placed over the needle placement sites and the patient returned to the supine position on a stretcher and transported to the recovery room without hemodynamic, neurologic, or allergic reactions. Fluoroscopic images were printed for hard copy recording and digitally archived. FLUOROSCOPIC INTERPRETATION: Appropriate epidurogram obtained. Appropriate lesioning of the 10 targets noted. POST PROCEDURE EVALUATION: The patient was comfortable in the recovery room. The patient is aware that pain may worsen before remitting and 4 – 6 weeks may be required prior to the onset of pain relief. IMPRESSION:

1. Technically successful sacral lateral branch, lumbar dorsal ramus and L4 medial branch neurotomy for denervation from L4-S3 on the LEFT/RIGHT without complication.

2. RTC in ___ weeks. 3. Estimated Blood Loss: ______ 4. Fluoroscopy time: ______ seconds

18


COOLIEF* Cervical Cooled RadiofrequencyCOOLIEF* 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:


cervical or thoracic, single facet joint


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












Device Codes:

There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* Probe Kit.



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.

19



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

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

353.2Cervical root lesions not elsewhere classified

G54.2Cervical root disorders not elsewhere classified

721.O Cervical spondylosis without myelopathy M47.812Spondylosis without myelopathy or radiculopathy, cervical region

M47.21Other spondylosis with radiculopathy, occipito-atlanto-axial region

M47.22Other spondylosis with radiculopathy, cervical region

M47.23Other spondylosis with radiculopathy, cervicothoracic region

M47.811Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region

M47.813Spondylosis without myelopathy or radiculopathy, cervicothoracic region

M47.891Other spondylosis, occiiito-atlanto-axial region

M47.892 Other spondylosis, cervical region

M47.893 Other spondylosis, cervicothoracic region

721.1 Cervical spondylosis with myelopathy M47.12Other spondylosis with myelopathy, cervical region

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

M47.021Vertebral artery compression syndromes, occipito-atlanto-axial region

M47.022Vertebral artery compression syndromes, cervical region

M47.11Other spondylosis with myelopathy, occipito-atlanto-axial region

M47.13Other spondylosis with myelopathy, cervicothoracic region

722.ODisplacement of cervical intervertebral disc without myelopathy

M50.20Other cervical disc displacement, unspecified cervical region

M50.21Other cervical disc displacement, high cervical region

M50.22Other cervical disc displacement, mid- cervical region

20


ICD-9 CODE


DESCRIPTION

M50.23Other cervical disc displacement, cervicothoracic region

722.4Degeneration of cervical intervertebral disc

M50.30Other cervical disc degeneration, unspecified cervical region

M50.31Other cervical disc degeneration, high cervical region

M50.32Other cervical disc degeneration,mid-cervical region

M50.33Other cervical disc degeneration, cervicothoracic region

722.71Intervertebral disc disorder with myelopathy cervical region

M50.00Cervical disc disorder with myelopathy, unspecified cervical region

M50.01Cervical disc disorder with myelopathy, high cervical region

M50.02Cervical disc disorder with myelopathy, mid-cervical region

M50.03Cervical disc disorder with myelopathy, cervicothoracic region

723.O Spinal stenosis in cervical region M48.02 Spinal stenosis, cervical region

M48.01 Spinal stenosis, occipito-atlanto-axial region

M48.03 Spinal stenosis, cervicothoracic region

M99.21Subluxation stenosis of neural canal of cervical region

M99.31Osseous stenosis of neural canal of cervical region

M99.41Connective tissue stenosis of neural canal of cervical region

M99.51Intervertebral disc stenosis of neural canal of cervical regiion

M99.61Osseous and subluxation stenosis of intervertebral foramina of cervical region

M99.71Connective 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

M50.10Cervical disc disorder with radiculopathy, unspecified cervical region

M50.11Cervical disc disorder with radiculopathy, high cervical region

M50.12Cervical disc disorder with radiculopathy,mid-cervical region

M50.13Cervical disc disorder with radiculopathy, cervicothoracic region

M54.11 Radiculopathy, occipito-atlanto-axial region

723.8 Occipital neuralgia M53.82Other specified dorsopathies, cervical region

M53.81Other specified dorsopathies, occipito-atlanto-axial region

M53.83Other specified dorsopathies, cervicothoracic region

M54.81 Occipital neuralgia

21


724.8 Facet syndrome- lumbar, cervical, thoracic M54.03Panniculitis affecting regions of neck and back, cervicothoracic region

M54.09Panniculitis affecting regions of neck and back, multiple sites in spine

733.13 Compression fracture (vertebral) M80.08XAAge-related osteopororosis with current pathologiacl fracture,vertebra€, initial encounter for fracture

M84.68XAPathological fracture in other disease, other site, initial encounter for fracture

M48.51XACollapsed verterbra, not elsewhere classified, occipito-atlanto-axial region, initial encounter for fracture

M48.52XACollapsed verterbra, not elsewhere classified, cervical region, initial encounter for fracture

M48.53XACollapsed verterbra, not elsewhere classified, cervicothoracic region, initial encounter for fracture

M80.88XAOther osteoporosis with current pathological fracture, vertebra€, initial encounter

M84.58XAPathological fracture in neoplastic disease, other specified site, initial encounter

847.O Neck sprain S13.4XXASprain of ligaments of cervical spine, initial encounter

S13.8XXASprain of joints and ligaments of other parts of neck, initial encounter

S16.1XXAStrain of muscle, fascia and tendon at neck level, initial encounter

953.O Injury to cervical nerve root S14.2XXAInjury of nerve root of cervical spine, initial encounter





submitted to the patient’s insurance carrier prior to performing the COOLIEF* Cervical Cooled

Radiofrequency Treatment.





required.







22







encourage you to make a strong case for the patient’s particular medical need for the cervical

medial branch neurotomy procedure.

23


Following is a sample letter of medical necessity for the COOLIEF* Cervical Cooled



[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.

24


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]

25




CERVICAL RADIOFREQUENCY


CERVICAL 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-guage (50mm/75mm) insulated sharp radiofrequency introducer 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 radiofrequency lesion of the medial branch of C4 was then performed at 80 degrees Celsius 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. IMPRESSION:

1. Successful bilateral C4, C5, and C6 cervical medial branch radiofrequency ablation. 2. Follow-up in 3 weeks to assess the efficacy of this procedure.

26


COOLIEF* Thoracic Cooled RadiofrequencyCOOLIEF* 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:


cervical or thoracic, single facet joint


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


RF lesion at T3-4 facet joint: 64633












Device Codes:




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.

27




RF denervation of thoracic facet nerves to treat the chronic pain caused by these medical



of the appropriate diagnosis code.

ICD-9 CODE


DESCRIPTION

353.3Thoracic root lesions, not elsewhere classified

G54.3Thoracic root disorders, not elsewhere classified


G55Nerve root and plexus compressios in diseases classified elsewhere

720.O Ankylosing spondylitis M45.0Ankylosing spondylitis of multiple sites in spine

M45.3Ankylosing spondylitis of cervicothoracic region

M45.4 Ankylosing spondylitis of thoracic region

M45.5Ankylosing spondylitis of thoracolumbar region

M48.8X3Other specified spondylopathies, cervicothoracic region

M48.8X4Other specified spondylopathies, thoracic region

M48.8X5Other specified spondylopathies, thoracolumbar region

M48.8X9Other specified spondylopathies, site unspecifiedthoracolumbar region

720.1 Spinal enthesopathy 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

721.2 Thoracic spondylosis without myelopathy M47.814Spondylosis without myelopathy or radiculopathy, thoracic region

M47.24Other spondylosis with radiculopathy, thoracic region

M47.25Other spondylosis with radiculopathy, thoracolumbar region

M47.815Spondylosis without myelopathy or radiculopathy, thoracolumbar region

M47.894 Other spondylosis, thoracic region

M47.895 Other spondylosis, thoracolumbar region

721.6 Ankylosing vertebral hyperostosis M48.13Ankylosing hyperostosis (Forestier), cervicothoracic region

M48.14Ankylosing hyperostosis (Forestier), thoracic region

M48.15Ankylosing hyperostosis (Forestier), thoracolumbar region

M48.19Ankylosing hyperostosis (Forestier), multiple sites in spine

28


ICD-9 CODE


DESCRIPTION

721.7 Traumatic spondylopathy M48.33Traumatic spondylopathy, cervicothoracic region

M48.34 Traumatic spondylopathy, thoracic region

M48.35Traumatic spondylopathy, thoracolumbar region

722.82Postlqaminectomy syndrome, thoracic region

M96.1Postlaminectomy syndrome, not elsewhere classified

724.1 Pain in thoracic spine M54.6 Pain in thoracic spine

724.4Thoracic or lumbosacral neuuritis or radiculitis, unspecified

M54.14 Radiculopathy, thoracic region

M54.15 Radiculopathy, thoracolumbar region

M51.14Intervertebral disc disorders with radiculopathy, thoracic region

M51.15Intervertebral disc disorders with radiculopathy, thoracolumbar region

724.8 Other symptoms referable to the back M54.03Panniculitis affecting regions of neck and back, cervicothoracic region

M54.04Panniculitis affecting regions of neck and back,thoracic region

M54.05Panniculitis affecting regions of neck and back,thoracolumbar region

M54.09Panniculitis affecting regions of neck and back,multiple sites in spine

729.2Unspecified neuralgia, neuritis, and radiculitis

M79.2 Neuralgia and neuritis, unspecified


29





submitted to the patient’s insurance carrier prior to performing the COOLIEF* Thoracic Cooled

Radiofrequency procedure.





required.












encourage you to make a strong case for the patient’s particular medical need for the thoracic


30


Following is a sample letter of medical necessity for the COOLIEF* Thoracic Cooled



[Date]

[Payer Address]


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

31


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




Sincerely,

[Doctor signature]

Dr. [doctor name]

32


Sample Operative Note THORACIC RADIOFREQUENCY


THORACIC RADIOFREQUENCY PATIENT: MRN: PREOPERATIVE DIAGNOSIS: POSTOPERATIVE DIAGNOSIS: PROCEDURE: 1. T4 Medial Branch Radiofrequency Denervation 2. T5 Medial Branch Radiofrequency Denervation 3. T6 Medial Branch Radiofrequency Denervation DATE OF PROCEDURE: ANESTHESIA: COMPLICATIONS: CONSENT: A full description of the procedure was provided including benefits as well as possible complications. All questions were answered and informed consent was given and signed. ASA guidelines for fasting were verified prior to sedation.

PROCEDURE IN DETAIL

The patient was brought into the procedure room and placed on the exam table in a comfortable prone position. A grounding pad was placed on the LEFT/RIGHT thigh. The thoracic region was widely prepped with a chloraprep solution, allowed to air dry and draped in standard sterile surgical fashion. Local anesthesia was provided by ___ mL of ___%_____ delivered with a 25g needle. Using intermittent fluoroscopy, a 17g 75mm radiofrequency introducer needle was perpendicularly placed at the inferior lateral aspect of the transverse process of T4 and guided until bony contact was felt. The introducer was then guided to the final placement at the superolateral aspect of the Right T4 transverse process. The stylet was removed and a radiofrequency probe with a 5.5mm active tip was inserted. Needle tip positon of the probe was verified in the AP, oblique and lateral views. The medial branch nerve was stimulated at 2Hz to a maximum of 1-2 volts to determine finalization of safe needle and electrode placement. A mixture consisting of _________ was slowly injected and then the target was lesioned at 80 degrees Celsius for 2 minutes and 30 seconds. The identical protocol was then conducted at the T5 and T6 levels. Tissue impedances were noted to be between 150 and 500 Ohms at each site. POST PROCEDURE EVALUATION: The patient tolerated the procedure well. After observation the patient was discharged with instructions and follow up. The patient was also provided contact information to call regarding any concerning symptoms or questions. IMPRESSION:

1. Successful thoracic medial branch radiofrequency ablations were performed without complication. 2. RTC in ___ week(s). 3. Estimated Blood Loss: ____ 4. Fluoroscopy time: ______ seconds

33


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:


lumbar or sacral, single facet joint


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


RF lesion at L3-4 facet joint: 64635

RF lesion at L4-5 facet joint: 64636

RF lesion at L5/S1 facet joint: 64636










Device Codes:


The miscellaneous surgical supply code, A4649, can be used 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 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.

34




RF denervation of lumbar facet nerves to treat the chronic pain caused by these medical



of the appropriate diagnosis code.

ICD-9 CODE


DESCRIPTION

353.1 Lumbosacral plexus lesions G54.1 Lumbosacral plexus disorders

353.4Lumbosacral root lesions, not elsewhere classified

G54.4Lumbosacral root disorders, not elsewhere classified


G55Nerve root and plexus compressions in diseases classified elsewhere

355.O Lesion of sciatic nerve G57.01 Lesion of sciatic nerve,right lower limb

G57.02 Lesion of sciatic nerve, left lower limb



720.1 Spinal enthesopathy 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

721.3Lumbosacral spondylosis without myelopathy

M47.817Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.26Other spondylosis with radiculopathy, lumbar region

M47.27Other spondylosis with radiculopathy, lumbosacral region

M47.816Spondylosis without myelopathy or radiculopathy, lumbar region

M47.896 Other spondylosis, lumbar region

M47.897 Other spondylosis, lumbosacral region

721.6 Ankylosing vertebral hyperostosis M48.10Ankylosing hyperostosis (Forestier), site unspecified

M48.16Ankylosing hyperostosis (Forestier), lumbar region

M48.17Ankylosing hyperostosis (Forestier), lumbosacral region

M48.19Ankylosing hyperostosis (Forestier), multiple sites in spine

721.7 Traumatic spondylopathy M48.36 Traumatic spondylopathy, lumbar region

M48.37Traumatic spondylopathy, lumbosacral region

722.83Postlaminectomy syndrome, lumbar region

M96.1Postlaminectomy syndrome, not elsewhere classified

722.93Other and unspecified disc disorder, lumbar region

M46.47 Discitis, unspecified, lumbosacral region

M51.86Other intervertebral disc disorders, lumbar region

M51.87Other intervertebral disc disorders, lumbosacral region

M46.46 Discitis, unspecified, lumbar region

35


ICD-9 CODE


DESCRIPTION

724.02 Spinal stenosis of the lumbar region M48.06 Spinal stenosis, lumbar region

M48.07 Spinal stenosis, lumbosacral region

M99.23Subluxation stenosis of neural canal of lumbar region

M99.33Osseous stenosis of neural canal of lumbar region

M99.43Connective tissue stenosis of neural canal of lumbar region

M99.53Intervertebral disc stenosis of neural canal of lumbar regiion

M99.63Osseous and subluxation stenosis of intervertebral foramina of lumbar region

M99.73Connective tissue and disc stenosis of intervertebral foramina of lumbar region


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

724.4Thoracic or lumbosacral neuritis or radiculitis, unspecified

M54.16 Radiculopathy, lumbar region

M54.17 Radiculopathy, lumbosacral region

M51.16Intervertebral disc disorders with radiculopathy, lumbar region

M51.17Intervertebral disc disorders with radiculopathy, lumbosacral region

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

M53.87Other specified dorsopathies, lumbosacral region

724.8 Other symptoms referable to the back M54.06Panniculitis affecting regions of neck and back, lumbar region


M54.09Panniculitis affecting regions of neck and back,multiple sites in spine

724.9 Other unspecified back disorders M43.8X9Other specified deforming dorsopathies, site unspecified

M43.26 Fusion of spine, lumbar region

M43.27 Fusion of spine, lumbosacral region

M53.80Other specified dorsopathies, site unspecified

M53.85Other specified deforming dorsopathies, thoracolumbar region

739.3Nonallopathic lesions of lumbar region, not elsewhere classified

M99.03Segmental and somatic dysfunction of lumbar region

739.4Nonallopathic lesions of sacral region, not elsewhere classified

M99.04Segmental and somatic dysfunction of sacral region

756.12 Cogenital spondylolisthesis Q76.2 Congenital spondylolisthesis


36



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.





required.












encourage you to make a strong case for the patient’s particular medical need for the lumbar


37




LUMBAR RADIOFREQUENCY


LUMBAR RADIOFREQUENCY

PATIENT: MRN: PREOPERATIVE DIAGNOSIS: Lumbar Spondylosis POSTOPERATIVE DIAGNOSIS: Lumbar Spondylosis PROCEDURE: Radiofrequency Ablation of medial branches - RT L1 L2 L3 L4 L5 / LT L1 L2 L3 L4 L5 DATE OF PROCEDURE: ANESTHESIA: MAC, Conscious Sedation, None COMPLICATIONS: None CONSENT: A full description of the procedure was provided including benefits as well as possible complications. All questions were answered and informed consent was given and signed. ASA guidelines for fasting were verified prior to sedation. PROCEDURE IN DETAIL The patient was brought into the fluoroscopy suite and positioned into the prone position on the fluoroscopy table and allowed to adjust to a position of comfort. A grounding pad was placed on the LEFT/RIGHT thigh. The lumbar region was widely prepped with a chloraprep solution, allowed to air dry and draped in standard sterile surgical fashion. Local anesthesia was provided by ____mL of ___% ____________ delivered with a 25 g needle. A 17g 75/100/150mm radiofrequency introducer needle was placed to the planned anatomic targets guided with intermittent fluoroscopy with a perpendicular approach to terminally place at the junction of the superior articular process and the transverse process of the LEFT/RIGHT L1 L2 L3 L4 L5 and the base of the sacral ala on the LEFT/RIGHT for the L5 medial branch nerve. The stylets were removed and radiofrequency probes with a 4mm active tip were then inserted. Needle tip position of the probes was verified in the AP, oblique, and lateral views. At each site, the medial branch nerve was stimulated at 2 Hz to a maximum 1-2 volts determined to finalize safe needle and electrode placement. The patient was awake and responsive during this portion of the procedure. Each target was anesthetized with 1-2 mL of ____% __________ for anesthesia for lesioning and then each target was lesioned at 80 degrees Celsius for 2 minutes and 30 seconds. Tissue impedences were noted to be between 250 and 500 Ohms. Electrodes and needles were then removed and bandages placed over the needle placement sites, the patient then returned to the supine position on a stretcher and transported to the recovery room without hemodynamic, neurologic, or allergic reactions. Fluoroscopic images were printed for hard copy recording and digitally archived. POST PROCEDURE EVALUATION: The patient was comfortable in the recovery room. The patient is aware that pain may worsen before remitting and 4 – 6 weeks may be required prior to the onset of pain relief. IMPRESSION:

1. Technically successful LEFT/RIGHT L1 L2 L3 L4 L5 medial branch radiofrequency neurotomy for denervation on the LEFT/RIGHT without complication.

2. RTC in ___ weeks. 3. Estimated Blood Loss: ____ 4. Fluoroscopy time: ______ seconds

38


COOLIEF* Knee Cooled RadiofrequencyCOOLIEF* 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.

39


Device Codes:


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.

40



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

715.16Osteoarthrosis, localized, primary, lower leg

M17.10Unilateral 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

715.26Osteoarthrosis, localized, secondary, lower leg

M17.5Other unilateral secondary osteoarthritis of knee

M17.2Bilateral post-tarumatic osteoarthritis of knee

M17.30Unliateral post-traumatic osteoarthritis, unspecified knee

M17.31Unilateral post-traumatic osteoarthritis, right knee

M17.32Unilateral post-traumatic osteoarthritis, left knee

M17.4Other bilateral secondary osteoarthritis of knee

716.16 Traumatic arthropathy, lower leg M12.561 Traumatic arthropathy, right knee

M12.562 Traumatic arthropathy, left knee

716.66 Unspecified monoarthritis, lower leg M13.169

M13.161Monoarthritis, not elsewhere classified, right knee

M13.162Monoarthritis, not elsewhere classified,left knee

716.86 Other specified arthropathy, lower leg M12.869Other 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

M12.861Other specific arthropathies, not elsewhere classified, right knee

M12.862Other specific arthropathies, not elsewhere classified, left knee


41







patient covered by Medicare sign an ABN (Advanced Beneficiary Notice).



required

• Provide the payer with the patient’s diagnosis and the appropriate CPT code




• Physician exam findings

• Copies of pertinent reports (MRIs, CT scans, etc.)



• Duration of diagnosis



encourage you to make a strong case for the patient’s particular medical need for genicular

neurotomy.

42


Following is a sample letter of medical necessity for the genicular neurotomy procedure to

assist you in drafting a pre-authorization request.


[Date]

[Payer Address]


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.

43


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


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




KNEE RADIOFREQUENCY


KNEE RADIOFREQUENCY 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 17g 75/100/150mm radiofrequency introducer 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 Celsius 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). This information cannot guarantee coverage or reimbursement for radiofrequency neurotomy and Halyard Health makes no other representations as to selecting codes for radiofrequency neurotomy or compliance with any other billing protocols or prerequisites. As with all claims, individual physicians and hospitals are responsible for exercising their independent clinical judgment in selecting the codes that most accurately reflect the patient’s condition and procedures performed for a patient. Physicians and hospitals should refer to current, complete, and authoritative publications such as AMA CPT lists or insurer policies for selecting codes and completing claims forms based on the care rendered to an individual patient, and may wish to contact individual carriers, fiscal intermediaries, or other third-party payers as needed.

45


COOLIEF* Hip Cooled RadiofrequencyCOOLIEF* 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

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

• 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:


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.

46



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

715.15Osteoarthrosis, 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

715.25Osteoarthrosis, localized, secondary, pelvic region and thigh

M16.7Other unilateral secondary osteoarthritis of hip

M16.2Bilateral osteoarthritis resulting from hip dysplasia

M16.30Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip

M16.31Unilateral osteoarthritis resulting from hip dysplasia, right hip

M16.32Unilateral osteoarthritis resulting from hip dysplasia, left hip

M16.4 Bilateral post-traumatic osteoarthritis of hip

M16.51Unilateral post-traumatic osteoarthritis, right hip

M16.52Unilateral post-traumatic osteoarthritis, left hip

M16.6Other bilateral secondary osteoarthritis of hip

716.15Traumatic arthropathy, pelvic region and thigh

M12.551 Traumatic arthropathy, right hip

M12.552 Traumatic arthropathy, left hip

716.25 Allergic arthritis, pelvic region and thigh M13.851 Other specified arthritis, right hip

M13.852 Other specified arthritis, left hip

716.55Unspecified polyarthropathy or polyarthritis, pelvic region and thigh

M13.0 Polyarthritis, unspecified

716.65Unspecified monoarthritis, pelvic region and thigh

M13.151Monoarthritis, not elsewhere classified, right hip

M13.152Monoarthritis, not elsewhere classified, left hip

716.85Other specified arthropathy, pelvic region and thigh

M07.651 Enteropathic arthropathies, right hip

M07.652 Enteropathic arthropathies,left hip

M12.851Other specific arthropathies, not elsewhere classified, right hip

M12.852Other specific arthropathies, not elsewhere classified, left hip

47


ICD-9 CODE


DESCRIPTION



719.65Other symptoms referable to joint, pelvic region and thigh

R29.4 Clicking hip

719.85Other specified disorders of joint, pelvic region and thigh

M25.859Other specified joint disorders, unspecified hip

M25.851 Other specified joint disorders, right hip

M25.852 Other specified joint disorders, left hip

726.5 Enthesopathy of hip region 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


48







patient covered by Medicare sign an ABN (Advanced Beneficiary Notice).



required

• Provide the payer with the patient’s diagnosis and the appropriate CPT code




• Physician exam findings

• Copies of pertinent reports (MRIs, CT scans, etc.)



• Duration of diagnosis



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.


[Date]

[Payer Address]


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.

49


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




Sincerely,

[Doctor Signature]

Dr. [Doctor Name]

Encl. [relevant diagnostic tests and results, patient’s pertinent medical history records, etc.]

50




HIP RADIOFREQUENCY Reference Material Only

HIP RADIOFREQUENCY PROCEDURE: 1. L/R articular branch of femoral nerve radiofrequency denervation 2. L/R articular branch of obturator nerve radiofrequency denervation 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 introducer 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 radiofrequency lesion of the articular branch of the femoral nerve was then performed at 80 degrees Celsius for 2 min 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 radiofrequency lesion of the articular branch of the obturator nerve was then performed at 80 degrees Celsius 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 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: This information cannot guarantee coverage or reimbursement for COOLIEF* Cooled Radiofrequency neurotomy and Halyard Health, Inc. makes no other representations as to selecting codes for radiofrequency neurotomy or compliance with any other billing protocols or prerequisites. As with all claims, individual physicians and hospitals are responsible for exercising their independent clinical judgment in selecting the codes that most accurately reflect the patient’s condition and procedures performed for a patient. Physicians and hospitals should refer to current, complete, and authoritative publications such as AMA CPT lists or insurer policies for selecting codes and completing claims forms based on the care rendered to an individual patient, and may wish to contact individual carriers, fiscal intermediaries, or other third-party payers as needed. 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: ________

51


AppealsFacilities 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

explana tion 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.

52


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]


[Title]


[Address]


RE: Denial of [Specify Procedure] procedure

[Patient Name]


[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.

53


[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,



54


CPT Codes 64450 64447 (femoral nerve) 64493 (L5 dorsal ramus) 64490 (First facet joint) 64490 (First facet joint) 64493 (First facet joint)Diagnostic (For each nerve) 64450 (obturator nerve) 64450 (S1 injection) 64491 (2nd facet joint) 64491 (2nd facet joint) 64494 (2nd facet joint)Injections 64450 (S2 injection) 64492 (Each additional facet joint) 64492 (Each additional facet joint) 64495 (Each additional facet joint)

64450 (S3 injection)CPT Codes 64640 64640 64635 (L5 dorsal ramus) 64633 (First facet joint) 64633 (First facet joint) 64635 (First facet joint)

Radiofrequency (For each nerve) (For each nerve) 64640 (S1 denervations) 64634 (Additional facet joints) 64634 (Additional facet joints) 64636 (Additional facet joints)Denervation 64640 (S2 denervations)

64640 (S3 denervations)Modifiers Add -50 modifier Add -50 modifier Add -50 modifier Add -50 modifier Add -50 modifier Add -50 modifier

for bilateral procedures for bilateral procedures for bilateral procedures for bilateral procedures for bilateral procedures for bilateral procedures

Add -59 modifier Add -59 modifier Add -59 modifier to CPT codes 64450 and 64640 to CPT code 64640 to CPT codes 64450 and 64640

for 2nd, 3rd, & 4th nerves for 2nd nerve (all levels)APC 5442 (64450) 5441 (64447) 5443 (64693) 5443 (64490) 5443 (64490) 5443 (64493)

CODES 5443 (64640) 5442 (64450) 5442 (64450) 5431 (64633) 5431 (64633) 5431 (64635)5443 (64640) 5431 (64635)

5443 (64640)HCPCS Code HOPD: A4649 HOPD: A4649 HOPD: A4649 HOPD: A4649 HOPD: A4649 HOPD: A4649

(Cooled RF Probe Kit) (Cooled RF Probe Kit) (Cooled RF Probe Kit) (Cooled RF Probe Kit) (Cooled RF Probe Kit) (Cooled RF Probe Kit)

Common M17.0 - M17.5 M25.551 - M25.552 M45.7 M54.2 M54.6 M54.30 - M54.32ICD-10 Codes M25.561 - M25.562 M16.0 - M16.6 M45.8 M47.11 - M47.13 M47.14 - M47.15 M54.40 - M54.42

M46.1 M47.811 - M47.813 M47.814 - M47.815 M54.5M47.27 M54.89

M47.817 - M47.818 M47.16M47.27 M47.817

M47.897M54.30 - M54.32M54.40 - M54.42

M54.5

Place of HOPD: 22 HOPD: 22 HOPD: 22 HOPD: 22 HOPD: 22 HOPD: 22Service ASC: 24 ASC: 24 ASC: 24 ASC: 24 ASC: 24 ASC: 24

Notes Bill for fluorscopic guidance Bill for fluorscopic guidance Fluoroscopic guidance included Fluoroscopic guidance included Fluoroscopic guidance included Fluoroscopic guidance included77002-26 77002-26 in CPT codes. No separate billing in CPT codes. No separate billing in CPT codes. No separate billing in CPT codes. No separate billing

(Physician billing only) (Physician billing only) HOPD & ASC: Bill only for first HOPD & ASC: Bill only for first HOPD & ASC: Bill only for first

facet joint using 64633 facet joint using 64633 facet joint using 64635

Subject to Multiple Subject to Multiple Subject to Multiple Subject to Multiple Subject to Multiple Subject to MultipleProcedure Discount Procedure Discount Procedure Discount Procedure Discount Procedure Discount Procedure Discount

Information provided in this table is intended for reference only. Complete information can be found in the respective section of the COOLIEF* Cooled RF Reimbursement Guide. Providers are responsible for documentation andfinal selection of reported services. The Current Procedure Terminology, Version 4 (CPT-4) is copyrighted by the American Medical Association. The Healthcare Common Procedure Code Services (HCPCS) and other mapping rulesare maintained by the Center for Medicare and Medicaid Services (CMS).

The intent of this table 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 responsibilityfor all claim submissions and reimbursement decisions. Each claim should be coded appropriately and supported with adequate documentation of the patient's medical record. The codes listed are examples of codes that may beappropriate for individual situations. These codes do not represent correct coding for all procedures involving our various COOLIEF* Cooled RF procedures.

COOLIEF* Lumbar Cooled Radiofrequency

COOLIEF* Cooled RF Quick Reference Table

COOLIEF* Knee Cooled Radiofrequency

COOLIEF* Hip Cooled Radiofrequency

COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency

COOLIEF* Cervical Cooled Radiofrequency

COOLIEF* Thoracic Cooled Radiofrequency

Appendix

*Registered Trademark or Trademark of Halyard Health, Inc. or its affiliates. © 2014 HYH. All rights reserved.

www.halyardhealth.com

CP141 C15949

*Registered Trademark or Trademark of Halyard Health, Inc. or its affiliates. © 2015 HYH. All rights reserved.

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.

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

For more information, please visit:www.halyardhealth.com

Call 1-844-HALYARD (1-844-425-9273) in the United States and Canada.

coolief* cooled radiofrequency reimbursement guide

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