RFA of nerves that supply the SI Joint

My phys is billing a 64999 for a radiofrequency ablation of the nerves that supply the SI joint. Pain Managemnt MD not anesthesiologist

I am in Wyoming. PT has Medicare, Noridian.

Planned Procedure: Right SI joint bipolar radiofrequency ablation

Pre/Post-Procedure Diagnosis:

1. Sacroiliitis IR Paravertebral Facet Joint Neurolysis 1 Facet Lumbar Sacral Bilateral

IR Paravertebral Facet Joint Neurolysis 1 Facet Lumbar Sacral Bilateral

Informed Consent: The patient's condition and proposed procedures, risks, benefits and alternatives were discussed with the patient in detail. All questions were answered in detail and the patient chose to proceed. Informed consent was obtained.

Time Out: A time out verifying correct patient, medical record number, allergies and surgical site was performed immediately prior to beginning the procedure.

IV: Peripheral IV access was not obtained.

Sedation: None

HPI: Ms. Behrmann is a 57 year old fmeale who presents with back pain. Previous treatment has included SI joint intraarticular injections which have relieved most of her pain but for short periods of time. She returns today for a radiofrequency ablation for longer term benefit. She had a left SI joint ablation done in October with some long-standing benefit. She would like to have this done on the right as well. It was verified with the patient and with the previous fluoroscopy images that she had this done on the left the last time. She presents for the right today.

Procedure Description

The SI joint on the right was visualized under fluoroscopy. The skin puncture sites were anesthetized with 2ml 1% Lidocaine. A radiofrequency needle with an active 100mm tip was advanced into the inferoposterior aspect of the left SI joint. Another needle was placed <1cm away from that needle. Radiofrequency needles were placed at the cephalad border as well with two needles approximately <1cm apart. The cannula was advanced at each level using oblique, AP and lateral guidance as needed. Final needle positioning was performed in the lateral fluoroscopic view, so that the needle tip overlaid the medial border of the SI joint. Once all needles were considered to be in a satisfactory fluoroscopic position, and in contact with bone, the probe was stimulated to assess for motor stimulation. This was done at >1.5mV without evidence of motor stimulation in his lower extremities. 1mL of 2% lidocaine was injected for anesthesia at the tip of the needle. The RFA machine was then set for parallel so that the two needles 1cm apart were ablated using bipolar ablation in parallel. This was then repeated at 4 other spots for a total of 6 bipolar radiofrequency ablations. Lesioning was then performed at 80 degrees Celsius for 90 seconds at each level. This was also done at the sacral ala to ablate the dorsal primary ramus of L5. The patient tolerated the procedure well. All needles were removed and Band-Aids were placed.

No immediate complications were observed.

Bilateral Procedure? NO

The heart rate, pulse oximetry, and blood pressure were continuously monitored throughout the procedure. XXXXX tolerated the procedure well.

Outcome: Patient's pain score was 6/10 before the procedure and 0/10 after the procedure. He stayed in the recovery room without motor and sensory deficits. After meeting discharge criteria, the patient was discharged home with his escort/driver.

Impression/Follow-Up: Ms. Behrmann will follow up in 4-6 weeks for follow-up care. He was instructed to call immediately if any of the following develops: new LE neuro symptoms, fever, worsening back pain, headache, or any other symptoms.

RFA of nerves that supply the SI Joint