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Thermal destruction of the intraosseous basivertebral nerve is a specialized procedure aimed at alleviating chronic low back pain. This technique specifically targets the basivertebral nerves, which are sensory nerves located within the center of the vertebral body and at the vertebral end plates. These nerves exit the vertebral body through the basivertebral foramen, and their activation is believed to contribute to "vertebrogenic" pain, a type of pain associated with degeneration of the intervertebral disc and the vertebral endplates. The procedure is performed using a transpedicular approach, which involves accessing the vertebral body through a small incision. Under fluoroscopic guidance, a trocar is introduced to facilitate access to the vertebral body. A curved cannula assembly is then utilized to create a tunnel through the vertebral body, allowing for precise targeting of the basivertebral nerve. To effectively destroy the nerve, a bipolar radiofrequency probe is employed, which applies energy to heat and ablate the nerve tissue, thereby interrupting the transmission of pain signals. This procedure is specifically coded as CPT® Code 64628 when performed on the first two vertebral bodies in the lumbar or sacral region, with additional vertebral bodies treated under CPT® Code 64629.
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The thermal destruction of the intraosseous basivertebral nerve is indicated for patients experiencing chronic low back pain that is believed to be generated by the basivertebral nerves. This pain is often associated with degeneration of the intervertebral disc and the vertebral endplates, leading to vertebrogenic pain. The procedure is typically considered when conservative treatments have failed to provide adequate relief, and the patient's symptoms are significantly impacting their quality of life.
The procedure begins with the patient positioned appropriately to allow for optimal access to the lumbar or sacral region. Under fluoroscopic guidance, a small incision is made to facilitate the insertion of an introducer trocar. This trocar is carefully advanced through the incision and into the vertebral body using a transpedicular approach. Once the trocar is in place, a curved cannula assembly is passed through the trocar to create a tunnel that leads directly to the basivertebral nerve. If necessary, a straight channeling stylet may be utilized to extend the channel further to ensure precise access to the nerve. Following the establishment of the channel, a bipolar radiofrequency probe is connected to a generator and introduced through the cannula. The probe is then activated to apply energy, which heats the basivertebral nerve, effectively destroying it and preventing the transmission of pain signals. This entire process is performed for the first two vertebral bodies, specifically in the lumbar or sacral region, as indicated by CPT® Code 64628.
After the procedure, patients are typically monitored for any immediate complications and may be advised on post-operative care, which can include pain management strategies and activity restrictions. Recovery time may vary, but patients are generally encouraged to gradually resume normal activities as tolerated. Follow-up appointments may be scheduled to assess the effectiveness of the procedure and to monitor for any potential side effects or complications.
| Short Descr | TRML DSTRJ IOS BVN 1ST 2 L/S | Medium Descr | THERMAL DSTRJ INTRAOSSEOUS BVN 1ST 2 LMBR/SAC | Long Descr | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | none | MUE | 1 |
This is a primary code that can be used with these additional add-on codes.
| 64629 | Add-on Code Resequenced Code MPFS Status: Active Code APC N Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) |
| SG | Ambulatory surgical center (asc) facility service | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | GC | This service has been performed in part by a resident under the direction of a teaching physician | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services | KX | Requirements specified in the medical policy have been met | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 73 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure prior to the administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GA | Waiver of liability statement issued as required by payer policy, individual case | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary | LT | Left side (used to identify procedures performed on the left side of the body) | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2022-01-01 | Added | Code added |
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