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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 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 herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-61000-34

Original Effective Date: 11/15/07

Reviewed: 03/23/17

Revised: 06/15/17

Subject: Neurolysis

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Update    
           

DESCRIPTION:

Radiofrequency neurolysis for facet joint pain

Facet joints (also called zygapophysial joints or z-joints), are posterior to the vertebral bodies in the spinal column and connect the vertebral bodies to each other, They are located at the junction of the inferior articular process of a more cephalad vertebra, and the superior articular process of a more caudal vertebra. These joints provide stability and enable movement, allowing the spine to bend, twist, and extend in different directions. They also restrict hyperextension and hyperflexion.

Facet joints are clinically important spinal pain generators in those with chronic spinal pain. Facet joints may refer pain to adjacent structures, making the underlying diagnosis difficult, as referred pain may assume a pseudoradicular pattern. Lumbar facet joints may refer pain to the back, buttocks, and lower extremities while cervical facet joints may refer pain to the head, neck and shoulders.

Imaging findings are of little value in determining the source and location of ‘facet joint syndrome’, a term referring to back pain caused by pathology at the facet joints. Imaging studies may detect changes in facet joint architecture, but correlation between radiologic findings and symptoms is unreliable. Although clinical signs are also unsuitable for diagnosing facet joint-mediated pain, they may be of value in selecting candidates for controlled local anesthetic blocks of either the medial branches or the facet joint itself. This is an established tool in diagnosing facet joint syndrome.

Radiofrequency neurolysis is a minimally invasive treatment for facet joint pain. It involves using energy in the radiofrequency range to cause necrosis of specific nerves (medial branches of the dorsal rami), preventing the neural transmission of pain. The objective of radiofrequency neurolysis is to both provide relief of pain and reduce the likelihood of recurrence. Radiofrequency neurolysis has been employed for over 30 years to treat facet joint pain.

Chemical neurolysis

Chemical neurolysis may be performed to provide pain relief for peripheral nerve pain. A chemical ablating agent (e.g., diluted phenol or alcohol) is injected into the nerve, with the intent of destroying the internal contents of the nerve while preserving its outer sheath.

NOTE: Peripheral nerve blocks, anti-inflammatory injections and local anesthetic injections into the soft tissue surrounding the nerve do not represent neurolysis.

Peripheral nerve pain may occur in the foot, as described below:

Morton’s neuroma

According to the National Institutes of Health National Library of Medicine, a neuroma is a thickening of nerve tissue that may develop in various parts of the body. The most common neuroma in the foot is a Morton’s neuroma, which occurs between the third and fourth toes. It is sometimes referred to as an intermetatarsal neuroma. “Intermetatarsal” describes its location in the ball of the foot between the metatarsal bones. Neuromas may also occur in other locations in the foot.

Symptoms of Morton’s neuroma include tingling, burning, or numbness; pain, a feeling that something is inside the ball of the foot, or a feeling that there’s something in the shoe or a sock is bunched up.

Ultrasound testing has been shown to be very effective in diagnosing neuromas. Because nerve tissue is not seen on an x-ray, the x-ray will not show the neuroma. A skilled foot specialist will be able to actually feel the neuroma on examination of the foot. Special studies such as MRI and CT scan have little value in the diagnosis of a neuroma.

Plantar Fasciitis

Plantar fasciitis is one of the most common complaints related to the foot. Plantar fasciitis is irritation and swelling of the thick tissue on the bottom of the foot. The plantar fascia is a very thick band of tissue that connects the heel bone to the toes. This band of tissue is what creates the arch of the foot. When the fascia is overstretched or overused, it can become inflamed. When the fascia is inflamed, it can be painful and can make walking more difficult.

The most common symptom is pain in the bottom of the heel, which is usually worse in the morning and may improve throughout the day. By the end of the day the pain may be replaced by a dull ache that improves with rest.

Other neuritis of the foot

Neuritis is the inflammation of a nerve. Other neuritic foot conditions include but are not limited to Tarsal Tunnel Syndrome, Medial Plantar Neuritis, Digital Neuritis, Deep Peroneal Neuritis, and Baxter’s nerve neuritis.

POSITION STATEMENT:

Paravertebral facet joint denervation (non-pulsed radiofrequency neurolysis)

Facet joint pain

Paravertebral facet joint radiofrequency neurolysis (denervation) meets the definition of medical necessity for the following:

Frequency of treatment

*Conservative non-operative therapy (spine) should include a multimodality approach consisting of a combination of active and inactive components. Inactive components, such as rest, ice, heat, modified activities, medical devices, acupuncture and/or stimulators, medications, injections (including trigger point), and diathermy can be utilized. Active modalities may consist of physical therapy, a physician supervised home exercise program**, and/or chiropractic care.

** A home exercise program (HEP) must consist of the following two elements:

  1. Information on an exercise prescription/plan is provided to the member
  2. Follow up is conducted (after 4-6 weeks), regarding completion of HEP or inability to complete HEP due to a physical reason (e.g., increased pain, inability to physically perform exercises). NOTE: member inconvenience or noncompliance without explanation does not constitute inability to complete a HEP.

Contraindications to facet joint denervation (radiofrequency neurolysis) include:

Radiofrequency neurolysis is considered experimental or investigational for all other conditions, as the available scientific evidence does not support conclusions regarding safety and effectiveness. These conditions include but are not limited to pain associated with the thoracic facet joints or the sacroiliac joint (SI) joints, or conditions of the foot (e.g., Morton’s neuroma, plantar fasciitis, and other foot pain).

All other methods of facet neurolysis are considered experimental or investigational, including but not limited to pulsed radiofrequency neurolysis, laser neurolysis, chemical neurolysis and cryoneurolysis.

Chemical neurolysis

Chemical neurolysis for foot pain meets the definition of medical necessity when ALL of the following criteria are met:

Morton’s neuroma:

Plantar fasciitis and other neuritis of the foot:

All other methods of neurolysis for conditions of the foot are considered experimental or investigational, as the published clinical evidence does not support conclusions regarding effects on health outcomes.

Documentation should clearly indicate the agent used for neurolytic destruction.

Medical necessity for imaging (fluoroscopic or ultrasound) performed with chemical neurolysis for conditions of the foot has not been established.

BILLING/CODING INFORMATION:

The following codes may be used to describe neurolysis:

CPT Coding

0440T

Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve (investigational)

0441T

Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve (investigational)

0442T

Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve) (investigational)

64620

Destruction by neurolytic agent, intercostal nerve (investigational)

64630

Destruction by neurolytic agent; pudendal nerve (investigational)

64632

Destruction by neurolytic agent; plantar common digital nerve

64633

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

64634

Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (list separately in addition to code for primary procedure)

64635

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

64636

Destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (list separately in addition to code for primary procedure)

64640

Destruction by neurolytic agent, other peripheral nerve or branch

Coding Notes:

Per CPT guidelines:

ICD-10 Diagnoses Codes That Support Medical Necessity

G57.51 – G57.52

Tarsal tunnel syndrome

G57.61 – G57.63

Lesion of plantar nerve

G57.81 – G57.82

Other mononeuropathies of lower limb

G57.91 – G57.92

Mononeuropathy of lower limb

M47.011 – M47.012

Anterior spinal artery compression syndromes, occipital and cervical regions

M47.016

Anterior spinal artery compression syndromes, lumbar region

M47.021 – M47.022

Vertebral artery compression syndromes, occipital and cervical regions

M47.11 – M47.12

Other spondylosis with myelopathy, occipital and cervical regions

M47.16

Other spondylosis with myelopathy, lumbar region

M47.21 – M47.22

Other spondylosis with radiculopathy, occipital and cervical regions

M47.26

Other spondylosis with radiculopathy, lumbar region

M47.811 – M47.812

Spondylosis without myelopathy or radiculopathy, occipital and cervical regions

M47.816

Spondylosis without myelopathy or radiculopathy, lumbar region

M47.891 – M47.892

Other spondylosis, occipital and cervical regions

M54.2

Cervicalgia

M54.31 – M54.32

Sciatica

M54.5

Low back pain

M96.1

Post-laminectomy syndrome, not elsewhere classified

REIMBURSEMENT INFORMATION:

Percutaneous non-pulsed radiofrequency neurolysis for facet joint pain:

64633 and 64634 in any combination, are limited to 12 in 12 months.

64635 and 64636 in any combination, are limited to 12 in 12 months.

Initial facet neurolysis may be performed on up to 3 cervical spinal levels or up to 3 lumbar spinal levels on a single date of service.

Facet neurolysis may be repeated at the same 3 levels previously treated once in 12 months, or facet neurolysis may be performed at different spinal levels in the same region (cervical or lumbar) 1 additional time in 12 months.

On a single date of service a facet joint can be treated unilaterally or bilaterally, depending on the location of the pain, with an appropriate modifier used to report a bilateral procedure.

Bilateral injections and unilateral injections are considered as equivalent in calculating the total number of procedures allowed per year.

Chemical neurolysis for Morton’s neuroma:

Total number of procedures (64632) is limited to five (5) in three (3) months. Each injection should be at least one (1) week apart.

Chemical neurolysis for plantar fasciitis and other neuritis of the foot: Total number of procedures (64640) is limited to five (5) in three (3) months. Each injection should be at least one (1) week apart.

NOTE: Services in excess of the limitations shown above are subject to medical review of documentation. The following information is required documentation to support medical necessity: physician history and physical, radiology study reports, physician progress notes with documentation of conservative treatment, treatment plan including narrative, physician operative report. Documentation must support “Position Statement” criteria and provide rationale for additional procedures.

LOINC Codes:

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Radiology

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan, plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Destruction of Paravertebral Facet Joint Nerve(s) (L29132) and Destruction by neurolytic agent; interdigital nerve of the foot—Morton’s Neuroma (L29130) located at fcso.com.

DEFINITIONS:

Chemical neurolysis: destruction of a nerve by injection of agent directly into the nerve.

Cryoneurolysis: destruction of a nerve with the use of extreme cold

Facet joint: each of four joints formed above and below and on either side of a vertebra by bony projections (articular processes). The smooth surface at the end of the bony projections is called a facet. Each vertebra has a bony projection on either side which angles downward on its lower side and a bony projection that angles upward on either side. The lower projections of one vertebra meet the upper projections of the vertebra below it, forming facet joints.

Medial branch block: injection of local anesthetic near the very small nerve branches that control sensation to the facet joints.

Morton’s neuroma: a thickening of the nerve present in the space between the third and fourth toes.

Neurolysis, denervation or neuro-ablation: destruction of a nerve.

Plantar fasciitis: inflammation of the band of tissue that connects the heel bone to the toes.

Radiofrequency neurolysis (radiofrequency lesioning): destruction of a nerve with the use of heat.

RELATED GUIDELINES:

Nerve Block Injections, 02-61000-29
Facet Joint Injections, 02-61000-30

OTHER:

None.

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-7269. Low back pain. Early management of persistent non-specific low back pain. National Institute for Health and Clinical Excellence (NICE); 2009 May.
  2. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-7479. Diagnosis and treatment of forefoot disorders. Section 3. Morton's intermetatarsal neuroma. Clinical Practice Guideline Forefoot Disorders Panel. March 2009.
  3. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-7951. Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010 Apr;112(4):810-33.
  4. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-8744. Management of acute low back pain. Michigan Quality Improvement Consortium. September 2011.
  5. AHRQ National Guideline Clearinghouse. Guideline Summary NGC-9259. Guideline for the evidence-informed primary care management of low back pain. Toward Optimized Practice; 2011.
  6. American Academy of Family Physicians. Plantar Fasciitis: A Common Cause of Heel Pain. ©2000 – 2010.
  7. American Chronic Pain Association. ACPA Consumer Guide to Pain Medication & Treatment 2011. Epidural, Nerve & Facet Blocks & Radiofrequency Ablation (Rhizotomy). (Accessed on 02/21/11).
  8. American Podiatric Medical Association. Treatment by Your Podiatric Physician: Neuromas. ©2010 American Podiatric Medical Association, Inc.
  9. American Podiatric Medical Association. Treatment by Your Podiatric Physician: Heel Pain. ©2010 American Podiatric Medical Association, Inc.
  10. American Podiatric Medical Association. What is a neuroma? Accessed at http://www.apma.org/ on 02/05/13.
  11. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010 Apr;112(4):810-33.
  12. Blue Cross Blue Shield Association Medical Policy Reference Manual. 6.01.23, Diagnosis and Treatment of Sacroiliac Joint Pain. February 2012.
  13. Blue Cross Blue Shield Association Medical Policy Reference Manual. 7.01.116, Facet Joint Denervation. October 2012.
  14. Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician. 2007 Jan; 10(1): 229-53.
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  16. Burnham RS, Holitski S, Dinu I. A Prospective Outcome Study on the Effects of Facet Joint Radiofrequency Denervation on Pain, Analgesic Intake, Disability, Satisfaction, Cost, and Employment. Arch Phys Med Rehabil Vol 90, February 2009.
  17. Bykowski JL, Wong WHW. Role of Facet Joints in Spine Pain and Image- Guided Treatment: A Review. Am J Neuroradiology 33:1419 –26 Sep 2012.
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  20. Civelek E, et al. Comparison of Effectiveness of Facet Joint Injection and Radiofrequency Denervation in Chronic Low Back Pain. Turkish Neurosurgery 2012, Vol: 22, No: 2, 200-206.
  21. ClinicalTrials.gov NCT01743326: RFD Versus Cervical Medial Branch Blocks in Chronic Degenerative Neck Pain. Maastricht University Medical Center. Last updated: December 13, 2012.
  22. Chua NHL, Vissers KC, Sluijter ME. Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications—a review. Acta Neurochir (2011) 153:763–771.
  23. Dobrogowski J, Wrzosek A, Wordliczek J. Radiofrequency denervation with or without addition of pentoxifylline or methylprednisolone for chronic lumbar zygapophysial joint pain. Pharmacol Rep. 2005 Jul-Aug; 57(4):475-80.
  24. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Radiofrequency Neuroablation for Low-Back Pain. Updated 10/20/06.
  25. ECRI Health Technology Assessment Information Services. Evidence Report. Radiofrequency Ablation for Chronic Spinal Pain. 04/07/10.
  26. Florida Medicare Part B Local Coverage Determination. L29132 Destruction of Paravertebral Facet Joint Nerve(s). 02/02/09. (Accessed 02/01/13).
  27. Florida Medicare Part B Local Coverage Determination. L29130 Destruction by neurolytic agent; interdigital nerve of the foot – Morton’s Neuroma. 02/02/09. (Accessed 02/01/13).
  28. Gofeld M, Jitendra J, Faclier G. Radiofrequency denervation of the lumbar zygapophysial joints: 10-year prospective clinical audit. Pain Physician. 2007 Mar; 10(2): 291-300.
  29. Gupta S, Gupta M, Nath S, Hess GM. Survey of European Pain Medicine Practice. Pain Physician 2012; 15:E983-E994.
  30. Hayes, Inc. Hayes Medical Technology Directory. Radiofrequency Ablation for Chronic Low Back Pain. Lansdale, PA: Hayes, Inc.; March 2007.
  31. Hayes, Inc. Hayes Medical Technology Directory. Radiofrequency Ablation for Cervical and Thoracic Back Pain. Lansdale, PA: Hayes, Inc.; March 2007.
  32. Institute for Clinical Systems Improvement (ICSI). Percutaneous Radiofrequency Ablation for Facet-Mediated Neck and Back Pain. ICSI Technology Assessment Report # 88. Bloomington, MN: ICSI; January 2005.
  33. InterQual 2010. Adult Procedures. Neuroablation, percutaneous.
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  36. Manchikanti KN, Atluri S, Singh V, Geffert S, Sehgal N, Falco FJE. Systematic Review: An Update of Evaluation of Therapeutic Thoracic Facet Joint Interventions. Pain Physician 2012; 15:E463-E481.
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  38. Manchikanti L, Damron K, Cash K, Manchukonda R, Pampati V. Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272. Pain Physician. 2006 Oct; 9(4): 333-46.
  39. Manchikanti L, Manchikanti KN, Manchukonda R, Cash KA, Damron KS, Pampati V, McManus CD. Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. Pain Physician. 2007 May; 10(3): 425-40.
  40. Manchikanti L, Singh V, Vilims BD, Hansen HC, Schultz DM, Kloth DS. Medial branch neurotomy in management of chronic spinal pain: systematic review of the evidence. Pain Physician. 2002 Oct; 5(4): 405-18.
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  54. Shabat S, Leitner Y, Bartal G, Folman Y. Radiofrequency treatment has a beneficial role in reducing low back pain due to facet syndrome in octogenarians or older. Clin Interv Aging. 2013;8:737-40.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

11/15/07

New Medical Coverage Guideline.

05/15/09

Scheduled review; update to description section to include medical necessity management statement, update position statement to include coverage criteria, and update to reimbursement statement limitations.

09/15/09

Update position statement.

07/15/10

Revisions consisting of Billing and Coding section changes to include coding guidelines.

11/15/10

Revision; MCG title changed to “Neurolysis”; updated description section to include chemical neurolysis for foot pain; updated position statement to include coverage criteria for neurolysis for foot pain; revised CPT coding to include 64632; revised coding notes; updated ICD-9 coding to include 355.5, 355.6, 355.79, 355.8 and 728.71; added related ICD-10 codes; revised reimbursement section; added Medicare exception; added MCG 02-61000-29 as a related guideline; updated references; reformatted guideline.

05/15/11

Scheduled review; position statement unchanged; references updated.

07/15/11

Revision; formatting changes.

10/15/11

Revision; added experimental/investigational coverage statement for neurolysis of sacroiliac (SI) joints; formatting changes.

01/01/12

Annual HCPCS coding update. Added 64633, 64634, 64635 and 64636. Deleted 64622, 64623, 64626 and 64627. Updated Coding Notes and Reimbursement Information sections.

03/15/12

Scheduled review. Revised description section, position statement and ICD9/ICD10 coding sections; deleted Medicare Advantage Program Exception; updated references and reformatted guideline.

07/15/12

Revision; added program exception for Medicare Advantage products.

03/15/13

Scheduled review. Revised position statement (chemical neurolysis is E/I for facet neurolysis). Revised description, ICD10 coding and Medicare Advantage program exception (added ICD9 and HCPCS codes). Updated references and reformatted guideline.

05/11/14

Revision: Program Exceptions section updated.

07/01/15

Scheduled review. Revised description and position statement. Updated references.

10/01/15

Revision; updated ICD10 coding section.

11/01/15

Revision: ICD-9 Codes deleted.

07/01/16

Quarterly CPT/HCPCS update. Added codes 0440T, 0441T, AND 0442T.

08/15/16

Revision; updated ICD10 coding section.

10/01/16

ICD-10 coding update: added code G57.63.

02/15/17

Revision; updated Reimbursement Information section.

04/15/17

Revision: updated pain relief criteria and frequency of treatment criteria for facet joint neurolysis. Updated references.

06/15/17

Revision: added codes 64620 and 64630.

Date Printed: June 23, 2017: 06:33 PM