COOLIEF* COOLED Revised 04/2016 …€¦ · RADIOFREQUENCY REIMBURSEMENT GUIDE ... which should be...
Transcript of COOLIEF* COOLED Revised 04/2016 …€¦ · RADIOFREQUENCY REIMBURSEMENT GUIDE ... which should be...
COOLIEF* COOLED RADIOFREQUENCYREIMBURSEMENT GUIDE
COOLIEF*Cooled Radiofrequency Systems
Revised 04/2016
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HALYARD* Pain Management Cooled RF Systems Reimbursement Guide
Table of Contents
• Introduction .......................................................................................................................... 2
• COOLIEF* TRANSDICAL* Disc Biacuplasty Cooled Radiofrequency ....................... 3
• COOLIEF* SINERGY* Sacroiliac Cooled Radiofrequency ........................................... 8
• COOLIEF* Cervical Cooled Radiofrequency ............................................................... 15
• COOLIEF* Thoracic Cooled Radiofrequency ..............................................................23
• COOLIEF* Lumbar Cooled Radiofrequency ................................................................29
• COOLIEF* Knee Cooled Radiofrequency .....................................................................33
• COOLIEF* Hip Cooled Radiofrequency ........................................................................40
• Appeals .................................................................................................................................46
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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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
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.
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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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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
RF lesions at S2: 64640-59
RF lesions at S3: 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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Medicare Billing
Effective July 1, 2013 Medicare published a notice that Modifier 59 should only be used, when
medically necessary, to unbundle a procedure code that has been bundled related to the
National Correct Coding Initiative (NCCI). Claims billed with the same procedure code two
or more times for the same date of service, should be submitted with the appropriate repeat
procedure modifier rather than using Modifier 59. Modifier 76 is used to report a service or
procedure that was repeated by the same practitioner subsequent to the original service or
procedure.
If billing a procedure code two or more times for the same date of service, the claim should
be submitted with the procedure code listed on one line without the 76 Modifier and each
subsequent procedure listed on a separate line using the Modifier 76.
When billing Medicare use the following approach in coding:
RF Lesion at L5/S1 facet joint: 64635
RF Lesions at S1: 64640
RF Lesions at S2: 64640-76
RF lesions at S3: 64640-76
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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ICD-9/ICD-10 Diagnosis Codes:
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
DESCRIPTIONICD-10 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
724.2 Lumbago M54.5 Low back pain
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
DESCRIPTIONICD-10 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
M54.07Panniculitis affecting regions of neck and back, lumbosacral 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
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 COOLIEF* SINERGY*
Sacroiliac Cooled RF Treatment.
Note: Medicare does not have a pre-authorization process. It is recommended that a potential
patient that 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 sacroiliac
joint neurotomy procedure.
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COOLIEF*Cooled Radiofrequency Systems
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.
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
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,
[Physician’s Name]
[Physician’s Practice Name]
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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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:
64633: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT);
cervical or thoracic, single facet joint
64634: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT);
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
RF lesion at C 4/5 facet joint: 64634
RF lesion at C 5/6 facet joint: 64634
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.
Device Codes:
There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* 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:
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.
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ICD-9/ICD-10 Diagnosis Codes:
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
DESCRIPTIONICD-10 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
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ICD-9 CODE
DESCRIPTIONICD-10 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
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COOLIEF*Cooled Radiofrequency Systems
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
For a complete list of coding options and descriptions, consult the current ICD-10-CM manual.
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 COOLIEF* Cervical Cooled
Radiofrequency Treatment.
Note: Medicare does not have a pre-authorization process. It is recommended that a potential
patient that 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)
19
COOLIEF*Cooled Radiofrequency Systems
• 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 cervical
medial branch neurotomy procedure.
20
COOLIEF*Cooled Radiofrequency Systems
Following is a sample letter of medical necessity for the COOLIEF* Cervical Cooled
Radiofrequency procedure to assist you in drafting a pre-authorization request.
SAMPLE LETTER OF MEDICAL NECESSITY
[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.
21
COOLIEF*Cooled Radiofrequency Systems
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]
22
COOLIEF*Cooled Radiofrequency Systems
Registered Trademark or Trademark of Halyard Health, Inc. and its affiliates. ©2015 HYH. All rights reserved. w
ww.HalyardHealth.com For more information, call 1-800-524-3577
Sample Operative Note COOLIEF* CERVICAL COOLED RADIOFREQUENCY Reference Material Only
COOLIEF* CERVICAL COOLED RADIOFREQUENCY PATIENT NAME: MRN:
PHYSICIAN:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
PROCEDURE: 1. C3 facet joint radiofrequency denervation2. C4 facet joint radiofrequency denervation3. 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-gauge (50mm/75mm) insulated sharp radiofrequency 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 thermal radiofrequency lesion of the medial branch of C4 was then performed at an average maximum tissue temperature greater than 80 degrees C 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 conce rning 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.
23
COOLIEF*Cooled Radiofrequency Systems
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:
64633: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT);
cervical or thoracic, single facet joint
64634: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT);
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
neurotomy is listed below:
RF lesion at T3-4 facet joint: 64633
RF lesion at T4-5 facet joint: 64634
RF lesion at T5-6 facet joint: 64634
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.
Device Codes:
There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* 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 thoracic facet joint pain varies significantly between payers.
As a result, a prior authorization from the payer is recommended.
24
COOLIEF*Cooled Radiofrequency Systems
ICD-9/ICD-10 Diagnosis Codes:
Following is a list of possible diagnosis codes which may support medical necessity for
RF denervation of thoracic 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 CODE
DESCRIPTIONICD-10 CODE
DESCRIPTION
353.3Thoracic root lesions, not elsewhere classified
G54.3Thoracic 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 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
25
COOLIEF*Cooled Radiofrequency Systems
ICD-9 CODE
DESCRIPTIONICD-10 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
For a complete list of coding options and descriptions, consult the current ICD-10-CM manual.
26
COOLIEF*Cooled Radiofrequency Systems
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 COOLIEF* Thoracic Cooled
Radiofrequency procedure.
Note: Medicare does not have a pre-authorization process. It is recommended that a potential
patient that 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 thoracic
medial branch neurotomy procedure.
27
COOLIEF*Cooled Radiofrequency Systems
Following is a sample letter of medical necessity for the COOLIEF* Thoracic Cooled
Radiofrequency procedure to assist you in drafting a pre-authorization request.
SAMPLE LETTER OF MEDICAL NECESSITY
[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 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
28
COOLIEF*Cooled Radiofrequency Systems
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
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]
29
COOLIEF*Cooled Radiofrequency Systems
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:
64635: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT);
lumbar or sacral, single facet joint
64636: Destruction by neurolytic agent, paravertebral facet joint nerve(s); (Fluoroscopy or CT);
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
neurotomy is listed below:
RF lesion at L3-4 facet joint: 64635
RF lesion at L4-5 facet joint: 64636
RF lesion at L5/S1 facet joint: 64636
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.
Device Codes:
There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* Probe Kit.
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.
30
COOLIEF*Cooled Radiofrequency Systems
ICD-9/ICD-10 Diagnosis Codes:
Following is a list of possible diagnosis codes which may support medical necessity for
RF denervation of lumbar 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 CODE
DESCRIPTIONICD-10 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
355.O Lesion of sciatic nerve G57.01 Lesion of sciatic nerve,right lower limb
G57.02 Lesion of sciatic nerve, left lower limb
719.45 Pain in joint, pelvic region and thigh M25.551 Pain in right hip
M25.552 Pain in left hip
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
31
COOLIEF*Cooled Radiofrequency Systems
ICD-9 CODE
DESCRIPTIONICD-10 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
724.2 Lumbago M54.5 Low back pain
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
M54.07Panniculitis affecting regions of neck and back, lumbosacral 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
For a complete list of coding options and descriptions, consult the current ICD-10-CM manual.
32
COOLIEF*Cooled Radiofrequency Systems
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 may be required
by the patient’s insurance carrier.
Note: Medicare does not have a pre-authorization process. It is recommended that a potential
patient that 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 lumbar
medial branch neurotomy procedure.
33
COOLIEF*Cooled Radiofrequency Systems
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
RF Lesion of inferomedial genicular branch from the saphenous nerve: 64640
Medicare Billing
Effective July 1, 2013 Medicare published a notice that Modifier 59 should only be used, when
medically necessary, to unbundle a procedure code that has been bundled related to the
National Correct Coding Initiative (NCCI). Claims billed with the same procedure code two
or more times for the same date of service, should be submitted with the appropriate repeat
procedure modifier rather than using Modifier 59. Modifier 76 is used to report a service or
procedure that was repeated by the same practitioner subsequent to the original service or
procedure.
If billing a procedure code two or more times for the same date of service, the claim should
be submitted with the procedure code listed on one line without the 76 Modifier and each
subsequent procedure listed on a separate line using the Modifier 76.
When billing Medicare use the following approach in coding:
RF Lesion of superolateral genicular branch from the vastus lateralis: 64640
RF Lesion of superomedial genicular branch from the vastus medialis: 64640-76
RF Lesion of inferomedial genicular branch from the saphenous nerve: 64640-76
34
COOLIEF*Cooled Radiofrequency Systems
Device Codes:
There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* 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.
35
COOLIEF*Cooled Radiofrequency Systems
ICD-9/ICD-10 Diagnosis Codes:
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
DESCRIPTIONICD-10 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
For a complete list of coding options and descriptions, consult the current ICD-10-CM manual.
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COOLIEF*Cooled Radiofrequency Systems
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 may be required
by the patient’s insurance carrier.
Note: Medicare does not have a pre-authorization process. It is recommended that a potential
patient 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 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 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 genicular
neurotomy.
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COOLIEF*Cooled Radiofrequency Systems
Following is a sample letter of medical necessity for the genicular neurotomy procedure to
assist you in drafting a pre-authorization request.
SAMPLE LETTER OF MEDICAL NECESSITY
[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-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.
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COOLIEF*Cooled Radiofrequency Systems
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
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]
Encl. [relevant diagnostic tests and results, patient’s pertinent medical history records, etc.]
39
COOLIEF*Cooled Radiofrequency Systems
Registered Trademark or Trademark of Halyard Health, Inc. and its affiliates. ©2015 HYH. All rights reserved. www.HalyardHealth.com For more information, call 1-‐800-‐524-‐3577
COOLIEF* KNEE COOLED RADIOFREQUENCY Cooled Genicular RFA 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 18 gauge 75 mm Halyard Health cooled radiofrequency 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 60° C 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).
Sample Operative Note
COOLIEF* KNEE COOLED RADIOFREQUENCY
Reference Material Only
40
COOLIEF*Cooled Radiofrequency Systems
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
Or
• 27299: Unlisted procedure, pelvis or hip joint
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
• If using the unlisted CPT code 27299, this code would be billed once.
• In addition, the physician can bill for fluoroscopic guidance using CPT code 77002-26.
Medicare Billing
Effective July 1, 2013 Medicare published a notice that Modifier 59 should only be used, when
medically necessary, to unbundle a procedure code that has been bundled related to the
National Correct Coding Initiative (NCCI). Claims billed with the same procedure code two
or more times for the same date of service, should be submitted with the appropriate repeat
procedure modifier rather than using Modifier 59. Modifier 76 is used to report a service or
procedure that was repeated by the same practitioner subsequent to the original service or
procedure.
If billing a procedure code two or more times for the same date of service, the claim should
be submitted with the procedure code listed on one line without the 76 Modifier and each
subsequent procedure listed on a separate line using the Modifier 76.
When billing Medicare use the following approach in coding:
• RF Lesion of femoral nerve: 64640
• RF Lesion of obturator nerve: 64640-76
Device Codes:
There are no specific HCPCS codes (C Code or pass-through code) for the COOLIEF* 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.
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COOLIEF*Cooled Radiofrequency Systems
ICD-9/ICD-10 Diagnosis Codes:
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
DESCRIPTIONICD-10 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
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COOLIEF*Cooled Radiofrequency Systems
ICD-9 CODE
DESCRIPTIONICD-10 CODE
DESCRIPTION
719.45 Pain in joint, pelvic region and thigh M25.551 Pain in right hip
M25.552 Pain in left hip
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
For a complete list of coding options and descriptions, consult the current ICD-10-CM manual.
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COOLIEF*Cooled Radiofrequency Systems
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 may be required
by the patient’s insurance carrier.
Note: Medicare does not have a pre-authorization process. It is recommended that a potential
patient 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 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 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 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.
SAMPLE LETTER OF MEDICAL NECESSITY
[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-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.
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COOLIEF*Cooled Radiofrequency Systems
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
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]
Encl. [relevant diagnostic tests and results, patient’s pertinent medical history records, etc.]
45
COOLIEF*Cooled Radiofrequency Systems
Registered Trademark or Trademark of Halyard Health, Inc. and its affiliates. ©2015 HYH. All rights reserved. www.HalyardHealth.com For more information, call 1-800-524-3577
Sample Operative Note
COOLIEF* HIP COOLED RADIOFREQUENCY
Reference Material Only
COOLIEF* HIP COOLED RADIOFREQUENCY
PROCEDURE: 1. L/R articular branch of femoral nerve radiofrequency denervation2. 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 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 thermal radiofrequency lesion of the articular branch of the femoral nerve was then performed at an average maximum tissue temperature greater than 80 degrees C for 2 minutes 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. Motortesting was then performed with ___ volts and no lower extremity motor stimulation was observed. ___cc _______% was injected through the RF needle. A thermal radiofrequency lesion of the articular branch of the obturator nerve was then performed at an average maximum tissue temperature greater than 80 degrees C 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 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: ________4. Disposition:_________
46
COOLIEF*Cooled Radiofrequency Systems
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.
47
COOLIEF*Cooled Radiofrequency Systems
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]
Attn: [Contact] usually the medical director
[Title]
[Name of Health Insurance Company]
[Address]
[City, State, ZIP Code]
RE: Denial of [Specify Procedure] procedure
[Patient Name]
[Policy Number/Group Number/Patient ID#]
[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.
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COOLIEF*Cooled Radiofrequency Systems
[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,
[Physician’s Name]
[Physician’s Practice Name]
*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.
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For more information, please visit:www.halyardhealth.com
Call 1-844-HALYARD (1-844-425-9273) in the United States and Canada.