64625 CPT Code Description, Guidelines, Reimbursement, Modifiers & Examples (2022)

64625 CPT code is discussed in this article, including a full description and easy-to-follow coding guidelines, applicable modifiers, and an example.

CPT Code 64625 Summary

CPT code 64625 refers to the radiofrequency ablation of the sacroiliac joint nerves under image guidance. It is used to manage chronic pain in the region innervated by the sacroiliac joint nerves.

The sacroiliac joint is between the articular surfaces of the iliac bone and the sacrum. It is a significant weight-bearing area as it supports the trunk’s weight. As a result, it is prone to strains with chronic back pain, subsequently a common occurrence.

The needle insertion is done under either fluoroscopy or computed tomography. The needle is inserted into the nerve supply to the sacroiliac joint.

Subsequently, an electromagnetic wave is passed through the needle. The heat produced by the electromagnetic wave will destroy and ablate the nerve.

Most patients are delighted with the results of radiofrequency therapy, which can dramatically reduce symptoms with no severe side effects.

Pain is probably the most common presenting complaint amongst patients, and managing pain can be difficult in some patients.

Hence, pain management is of utmost importance. As a result, there are various approaches and therapies for pain management (diagnostic/therapeutic) procedures with proven results, and a prominent example is the radiofrequency ablation of nerves.

Radiofrequency ablation is a standard procedure in clinical therapeutics that involves using radiofrequency waves to destroy abnormal tissue or growth in the body.

It is used not only in treating chronic pain but also in treating a wide variety of other conditions, such as benign and malignant tumors, venous insufficiency of the leg, etc.

In this procedure, a needle is inserted into the target site of destruction in the body. The needle is inserted under the guidance of an imaging technique, computed tomography, or fluoroscopy.

With an electrode connected to the needle, a radiofrequency wave is passed through the needle into the target tissue or mass, generating the heat necessary to destroy the tissue.

There are three main techniques of radiofrequency ablation with slightly different approaches. These include conventional/traditional radiofrequency, pulse radiofrequency, and cooled radiofrequency ablation.

In conventional radiofrequency ablation, an electrical current is applied through a needle with a resultant delivery of high temperature, usually above 60⁰C, and for at least 40 seconds.

However, for the pulse radiofrequency ablation, a high electrical current is applied in short pulses (for 20-ms every 0.5secs) to keep the temperature within acceptable limits, i.e. less than 42⁰C.

On the other hand, cooled radiofrequency ablation involves the delivery of high-frequency electrical current to the nerve through water-cooled electrodes or probes.

The advantage of the cooled over the other techniques is that it produces a more significant ablative lesion on the nerve.

It is a minimal procedure that can be done in an outpatient setting as it requires no general anesthesia.

Patients can go home the same day if done in the hospital.

64625 CPT Code Description

CPT 64625 refers to the radiofrequency ablation of the sacroiliac joint nerves under guidance such as fluoroscopy, computed tomography, or ultrasound.

As already stated, it can be done using a cooled pulse or conventional radiofrequency technique. It is essential because different CPT codes account for each technique.

Before 2020, the radiofrequency ablation of nerves of the sacroiliac joints nerves using conventional or cooled radiofrequency techniques was billed under the code CPT 64999.

However, following the 2020 CPT guidelines, the radiofrequency ablation of sacroiliac joint nerves using conventional or cooled radiofrequency techniques is now reported under CPT 64625.

Also, the radiofrequency ablation of sacroiliac joint nerves using the pulsed radiofrequency technique is reported with CPT code 64999, which also describes other unlisted procedures on the nervous system.

When CPT 64625 is done under ultrasound guidance, it is reported with CPT code 76999 (code for interventional or diagnostic ultrasound procedures). A bilateral procedure necessitates the use of modifier 50 to qualify it better.

Some other denervation procedures can be done in the same session as the CPT 64625 procedure, e.g. CPT code 64635, which describes the neurolytic destruction of paravertebral facet nerves.

However, the CPT 64625 procedure should not be reported together with CPT 64635.

Also, CPT 64625 should not be reported by a medical coder along with fluoroscopic or other imaging guidance techniques for specific procedures such as 77002, CPT code 77003, 77012, 95873, and 95874.

Also, it should not be stated with specific codes for imaging guidance techniques for chemodenervation

ICD-10 codes that indicate the medical necessity for this procedure must be submitted along with the CPT code by the coder. The CPT 64625 procedure is required to meet the guideline standards and be reasonable in particular circumstances.

There are other specific guidelines used in coding these procedures. For example, recommendations state that CPT 64625 should be reported once by the coder regardless of the number of nerves ablated in a single procedure.

CPT guidelines also distinguish between codes incorporating image guidance and those that require it to be reported separately.

It is worth noting that one is not clinically required to undertake radiofrequency ablation for denervation using conventional, cooled, or pulsed radiofrequency because it is deemed experimental.

64625 CPT Code Billing Guidelines & Reimbursement 

When CPT code 64625 and another pain management procedure with a specific CPT code (for example, CPT 64635) are done in the same surgery session, they cannot be billed together.

Instead, only one of the procedures is reported, and the other procedure is indicated through the use of modifier 59. It would prevent billing for both procedures done at the same time, as only one is being billed.

For example, when a surgeon performs destruction of lumbar facet nerves during a radiofrequency ablation procedure of the sacroiliac joint, the whole procedure is billed under CPT code 64625 with the addition of modifier 59 to indicate the lumbar facet nerve destruction being done.

The cost for the 64625 procedure varies depending on where it’s being carried out. The cost for in-office and in-facility physician fees is $510 and $202, respectively, with the total RVU at 14.14 and 5.59.

The outpatient hospital cost is $1719, while the payment fee for the ambulatory surgical centre is $797.

Adequate documentation is key to the successful reimbursement of this procedure. The primary documentation to prove medical necessity will determine if follow-up or staged operations are necessary.

The documentation should include the patient’s history, the procedure done and the clinical indication for the procedure.

When the physician offers a radiofrequency ablation procedure, the patient’s medical record should specifically describe the indication for the procedure, along with the anticipated results and suggested therapy.

The operational notes should include the patient’s name and medical record number, diagnosis, the procedure to perform, procedure date, evidence of consent, anesthesia, procedure complications, clear description of the procedure, and evaluation of the patient after the procedure with impressions.

The patient’s medical record should contain proof that adequately supports the therapeutic need of the treatments covered by the LCD.

This paperwork also contains, but is not restricted to, essential health records, medical examinations, and diagnostic tests or procedure findings.

A technique note should be readable and contain enough information to allow the treatment to be reconstructed.

A statement of the procedures used, injection sites(s), medicines and dosage with amounts and concentrations, and initial and post-procedural pain evaluations are all required aspects of the note.

64625 Modifiers

The following modifiers are used in association with CPT code 64625.

Modifier 50:

Modifier 50 is only appended when the SIJ nerve ablation is done bilaterally, i.e., on nerves of both sacroiliac joints of the body. Modifier 50 has nothing to do with ultrasound guidance.

For example, a surgeon performs SIJ nerve ablation on both Sacroiliac joints (bilaterally). This procedure is reported as CPT 64625 + modifier 50.

Modifier LT & RT: On the other hand, the LT and RT modifiers are used to report the CPT 64625 procedure unilaterally. If the procedure was done on the left sacroiliac joint, it is written as LT, while RT is for reporting the procedure on the right sacroiliac joint.

Modifier 59: As stated early, this is used for distinct procedural services. It indicates different or standalone services that are not generally stated together. The physician must document the different services.

Modifier XS: This indicates that this procedure was performed on a separate and distinct structure or organ. For example, the radiofrequency ablation of the knee joint during the 64625 procedure can be billed with CPT 64625.

For an Ambulatory Surgical Center (ASC), the relevant site prefix (RT or LT) must be applied to an Ambulatory Surgical Center (ASC) to specify whether the procedure was provided unilaterally or bilaterally by the physician.

The service provider will use the RT and LT modifiers to indicate bilateral services on distinct lines. However, the use of modifier 50 is not allowed.

Example

A 23-year-old Active Duty woman is about to be discharged from the military unwillingly due to a treatable medical issue. Since sustaining a work-related accident, she has suffered severe low back pain that travels through her hip and down her leg. 

Before being sent to the chronic pain clinic, she had seen several doctors during the previous 11 months. However, she was diagnosed with sacroiliac joint dysfunction during her first visit to the chronic pain clinic.

To treat the pain, the physician performed a radioactive ablation of the nerve supply to the sacroiliac joint. 

The procedure is coded with the 64625 CPT code and billed accordingly.